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Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_4 | Pages 21 - 21
1 Apr 2022
Chatterji U Puttock D Sandean D Kheiran A Mundy G Menon D Brown A
Full Access

There is sufficient evidence that specialised orthopaedic services, in the form of ‘hub’ or specialist centres, which undertake a high volume of workload in revision arthroplasty generate superior outcomes.

The East Midlands South Orthopaedic Network (EMSSON) was set up in 2015 and is an example of a ‘hub and spoke’ network. The network has recently undergone adaptation in light of the COVID-19 pandemic. There is paucity of data considering the impact of such adaptations in a post-pandemic era and on adherence to advice given.

Two data sets were obtained from the EMSSON data base, pertaining to pre and post pandemic eras respectively. Datasets were analysed and compared for case volumes, proportion of overall arthroplasty volume discussed and adherence to agreed management plans.

Dataset one included 107 cases, of these 99 cases were discussed (54 knees and 45 hips). This equates to 35% of total revision arthroplasty volume recorded in the National Joint Registry (NJR), by units involved in the network. A change of plan was recommended in 45/99 cases (45%), of these 41 (93%) were adhered to. Dataset two included 99 cases, of these 98 were discussed (39 knees and 59 hips). This equates 68% of revision arthroplasty volume performed by the region according to NJR records. A change in plan was recommended in 20 cases (20.5%), all of which were adhered to. One case was referred to the ‘hub’ for surgery.

Following the implementation of recent adaptations, the efficiency of the EMSSON network has significantly improved. A greater volume and proportion of revision arthroplasty cases are now being discussed on a weekly basis. Management plans for which adaptations are suggested have decreased, indicating an educational value of such networking practices. Adherence to agreed plans also showed improvement (p<0.03).

These findings demonstrate a trend towards NHS England's target of 100% of revision arthroplasty cases undergoing MDT discussion. Changes made in light of the Covid-pandemic, are felt to have contributed significantly to the overall performance of regional networking and have been well received by consultants involved.


The Bone & Joint Journal
Vol. 102-B, Issue 2 | Pages 170 - 176
1 Feb 2020
Bernthal NM Burke ZDC Hegde V Upfill-Brown A Chen CJ Hwang R Eckardt JJ

Aims

We aimed to examine the long-term mechanical survivorship, describe the modes of all-cause failure, and identify risk factors for mechanical failure of all-polyethylene tibial components in endoprosthetic reconstruction.

Methods

This is a retrospective database review of consecutive endoprosthetic reconstructions performed for oncological indications between 1980 and 2019. Patients with all-polyethylene tibial components were isolated and analyzed for revision for mechanical failure. Outcomes included survival of the all-polyethylene tibial component, revision surgery categorized according to the Henderson Failure Mode Classification, and complications and functional outcome, as assessed by the Musculoskeletal Tumor Society (MSTS) score at the final follow-up.


The Bone & Joint Journal
Vol. 102-B, Issue 1 | Pages 102 - 107
1 Jan 2020
Sharma N Brown A Bouras T Kuiper JH Eldridge J Barnett A

Aims

Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the standard for classifying trochlear dysplasia, but numerous studies have reported poor reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI-specific classification system to assess the severity of trochlear dysplasia, the Oswestry-Bristol Classification (OBC). This is a four-part classification system comprising normal, mild, moderate, and severe to represent a normal, shallow, flat, and convex trochlear, respectively. The purpose of this study was to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification.

Methods

Four observers (two senior and two junior orthopaedic surgeons) independently assessed 32 CT and axial MRI scans for trochlear dysplasia and classified each according to the OBC and the Dejour classification systems. Assessments were repeated following a four-week interval. The inter- and intraobserver agreement was determined by using Fleiss’ generalization of Cohen’s kappa statistic and S-statistic nominal and linear weights.


The Bone & Joint Journal
Vol. 101-B, Issue 6 | Pages 724 - 731
1 Jun 2019
Bernthal NM Upfill-Brown A Burke ZDC Ishmael CR Hsiue P Hori K Hornicek F Eckardt JJ

Aims

Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique.

Patients and Methods

A review of 658 consecutive, prospectively collected cemented endoprosthetic reconstructions for oncological diagnoses at a single centre between 1980 and 2017 was performed. A total of 51 patients were identified with 56 endoprosthetic implants with cross-pin fixation, 21 of which were implanted following primary resection of tumour. Locations included distal femoral (n = 36), proximal femoral (n = 7), intercalary (n = 6), proximal humeral (n = 3), proximal tibial (n = 3), and distal humeral (n = 1).


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_6 | Pages 29 - 29
1 May 2019
Raheman F Berber R Maercklin L Watson E Brown A Ashford R
Full Access

Introduction

Renal impairment following major surgery is a formidable complication. There is recent evidence suggesting increasing risk of progression to chronic kidney disease and mortality after transient renal impairment. We aimed to evaluate the impact of pre-operative comorbidities on long-term outcomes of renal-function following hip arthroplasty.

Method

Patients listed for hip arthroplasty were pre-assessed according to the Charlson-Comorbidity-index (CCI) in May 2017. Demographic data, established risk factors and preoperative renal-function were collected. Pre-existing renal dysfunction was classified using KDIGO CKD criteria. RIFLE AKIN scores were used to document post-operative renal impairment based on 7-day serum creatinine. Renal function was assessed at 30 day and 1 year. Risk for early and long-term-complications were determined by univariate and multivariate analysis. Mortality and kidney-disease-progression were estimated using Kaplan Meier plots


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_5 | Pages 137 - 137
1 Apr 2019
Oladokun A Vangolu Y Aslam Z Harrington J Brown A Hall R Neville A Bryant M
Full Access

Introduction

Titanium and its alloys are attractive biomaterials attributable to their desirable corrosion, mechanical, biocompatibility and osseointegration properties. In particular, β – titanium alloys like the TMZF possess other advantages such as its lower modulus compared to Ti6Al4V alloy. This reduces stress shielding effect in Total Hip Arthroplasty (THA) and the replacement of V in the Ti6Al4V alloy, eliminates in-vivo V-induced toxicity. Unfortunately, implants made of TMZF were later recalled by the FDA due to higher than acceptable revision rates. The purpose of this study was to compare the fretting corrosion characteristics of Ti6Al4V and TMZF titanium alloys. It is hoped the findings will inform better design of β – titanium alloys for future applications in THA.

Method

A ball-on-flat configuration was utilised in this study to achieve a Hertzian point contact for CoCrMo – Ti6Al4V and CoCrMo – TMZF material combinations. These were assessed at a fretting displacement of ±50 µm at an initial contact pressure of 1 GPa. Each fretting test lasted 6000 cycles at a frequency of 1 Hz. A two-electrode cell set-up was used to monitor in-situ open circuit potential (OCP). The simulated physiological solution consisted of Foetal Bovine Serum (FBS) diluted to 25% with Phosphate Buffered Saline (PBS) and 0.03% Sodium Azide (SA) balance. The temperature was kept at ∼37°C. Corrosion products on the worn surfaces and subsurface transformations in both alloys were characterised using the Scanning and Transmission Electron Microscopy (SEM/TEM) to obtain high resolution micrographs. The samples were prepared using a FIB-SEM. Bright-field, dark-field and selected area electron diffraction (SAED) patterns were all captured using a scanning TEM (STEM) and Energy Dispersed X-Ray spectroscopy (EDX) mapping was carried out.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 546 - 546
1 Nov 2011
Ibrahim T Aswad MG Dias J Esler C Brown A
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Introduction: To report the 11-year follow-up of patients of contaminated femoral heads donated at primary total hip replacement from a cohort study published in 2004.

Methods: Of the 440 donors, 266 patients (61%) were still alive at a mean of 11.7 years post primary total hip replacement and 170 patients (64%) agreed to review. The patients had either a positive or negative culture from their donated femoral head at primary total hip replacement. The Oxford hip score, European Quality of Life (EuroQOL) questionnaire, rates of complication and revision surgery were used as outcome measures.

Results: At long-term follow-up, the Oxford hip score was not different between the positive (mean = 36, standard deviation = 12.3) and sterile (mean = 39, standard deviation = 10.9) groups (p = 0.40). The EuroQOL questionnaire was also not different between the positive and sterile groups. There was no statistically significant difference in the rate of complications (p = 0.93) and revision surgery (p = 0.11) of the age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile.

Discussion: The results of this 11-year follow-up of contaminated donated femoral heads cohort study were similar to those at short-term follow-up. Culture results of donated femoral heads play no significant role in predicting failure of primary total hip replacement in the donor at long-term follow-up.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 80 - 80
1 Mar 2009
Ibrahim T Rowsell M Rennie W Brown A Taylor G Gregg P
Full Access

We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review.

The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group.

The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_III | Pages 285 - 285
1 Nov 2002
Brown A Wood D
Full Access

Introduction: Transmission of infection is always a concern in allograft bone banking and the surgical applications of such bone.

Aim: To review the microbiological results of the femoral head donor program at Perth Bone and Tissue Bank from March 1992 until April 2001.

Methods: There were 4515 femoral head donations. All were cultured by means of a swab and bone chip at time of retrieval, prior to storage at −75 degrees C. Once six month repeat serological testing of donors had been obtained, the heads were processed under sterile conditions. All soft tissues were removed, the bone was milled and washed with 1.5 litres warm saline as pulsed lavage. A microbiological swab was taken prior to packaging the graft ready for irradiation and freezer storage until use.

Results: Five hundred and seventy-nine femoral heads had a positive swab or chip at retrieval, with 31 cases having the same organism on both tests. In 516 cases only one of these tests was positive, with skin organisms being the dominant finding. In 10 cases the swab at the end of processing was positive on culture. Eight of these cases were negative on retrieval testing, and in only one case was the same organism, a coagulase negative staphylococcus, present on the processing swab and retrieval testing.

Conclusions: This work suggested that microbiological culture of femoral head swabs and bone chips at time of retrieval has little effect on the culture at the end of processing. After storage at −75 degrees C, mechanical cleaning and washing, less than 1% of femoral heads were positive prior to irradiation.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_III | Pages 275 - 275
1 Nov 2002
Wood D Brown A Salleh R Robertson B Zheng M
Full Access

Articular cartilage defects of the knee occur commonly in sports injuries and trauma. Increasing evidence suggests that the only technique that enables the regeneration of articular hyaline cartilage in chondral defects is autologous chondrocyte implantation (ACI). Here we have reported our clinical experience of autologous chondrocyte implantation using biodegradable type I/III collagen membrane (CACI). A total of 26 patients (age range from 19 to 60 years, average 37 years) was conducted with CACI. Pre-operative magnetic resonance imaging (MRI) scans were performed on all patients. Post-operative MRI scans were planned for approximately three and 12 months after the surgery to determine the success of integration of implanted chondrocytes.

The results demonstrated that the initial post-operative MRI scans at three months showed the presence of oedematous tissue at the defect sites in 23 patients, contrasting with the fluid filled defects seen preoperatively and with and MRI signal differing from that of the surrounding normal hyaline articular cartilage. MRI scans in nine patients at 12 months after their operations showed maturation of cartilage graft in all patients. Apopototic testing of the chondrocytes using Annexin IV before implantation showed that the viability of the chondrocytes was over 85% where the apopototic rate of chondrocytes was less than 2%. One patient with an apopototic rate of over 10% has a delayed repair in cartilage defects as shown by MRI.

In conclusion, early phase clinical studies showed that autologous chondrocyte implantation remains promising for the treatment of chondral defects with restoration of hyaline cartilage. Longer clinical follow-up of the patients and better assessment of cellular phenotype of chondrocytes before implantation are required.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_III | Pages 285 - 285
1 Nov 2002
Brown A Vicca A Taylor G
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Introduction: Deep infection remains a major complication of joint arthroplasty. Major randomised controlled trials to determine the most effective antibiotic prophylaxis are difficult to construct and interpret. In a conventional theatre most orthopaedic intraoperative wound contamination arrives by the airborne route.

Aim: To use a unique method to compare antibiotics against these airborne bacteria.

Method: Seven antibiotics were tested; Cephradine, Cefuroxime, Cefotaxime, Flucloxacillin, Amoxycillin, Co-amoxyclav and Imipenem. They were incorporated into blood agar at concentrations equivalent to serum levels. Plates were then inoculated with airborne theatre bacteria using a multiple synchronous collection technique. After incubation, the percentage kills were calculated for each antibiotic.

Results: At concentrations equivalent to serum levels one hour following an intravenous dose all of the antibiotics proved highly effective, with kill rates greater than 95%. Imipenem and Co-amoxiclav significantly outperformed the other antibiotics with kill rates of 99.6% and 99.4% respectively. At trough levels the antibiotics achieved kill rates from 61% to 97.6%.

Discussion: Future randomised controlled trials comparing antibiotics in the setting of an already low infection rate are inappropriate. This technique for comparing antibiotic prophylaxis is quick, inexpensive and repeatable. The superiority of Imipenem is not unexpected, given its broad spectrum against both gram positive and negative, aerobic and anaerobic bacteria. Of more interest is the effectiveness of Co-amoxiclav over the presently favoured Cefuroxime.


The Journal of Bone & Joint Surgery British Volume
Vol. 53-B, Issue 3 | Pages 420 - 424
1 Aug 1971
Brown A D'Arcy JC

1. A method of internal fixation for the supracondylar fracture of the femur in the elderly patient is presented.

2. The fixation obtained allows the unsupported use of the limb and early partial weightbearing. Convalescence is thereby considerably shortened.

3. The disappointing results of internal fixation previously reported can be largely related to poor methods of fixation.


The Journal of Bone & Joint Surgery British Volume
Vol. 50-B, Issue 2 | Pages 369 - 371
1 May 1968
Brown A

1. A simple method of subtalar fusion, suitable for use in children, is described.

2. Although it is intended to provide stability for some years until a complete subtalar fusion can be carried out, further operation may not be necessary.

3. Its use is not advocated over the age of eleven or twelve.


The Journal of Bone & Joint Surgery British Volume
Vol. 33-B, Issue 4 | Pages 594 - 597
1 Nov 1951
Costello FV Brown A

1. Three cases of poliomyelitis complicated by myositis ossificans are reported.

2. A search of the literature has failed to reveal any similar reported cases.

3. The cause is still obscure.