We present a single surgeon series of 20 modified Dunn osteotomies without surgical dislocation of the femoral head for slipped upper femoral epiphysis (SUFE). All patients from 2007 to 2011 who had a Dunn osteotomy for SUFE had their notes reviewed and we obtained an updated Non Arthritic Hip Score.Introduction
Method
Modular hip designs offer potential for customising the implant to the patient. However, the more features a device has to offer, the potential for misuse increases. This paper will review one modular stem and the pearls learned over the years to make this a simple and reproducible surgical technique. Over a 1,000 primary THA have been performed since the development of the proximal modular stem in 2000. The two senior surgeons developed the stem design and surgical techniques used and described here. Two additional surgeon co-authors have used the device as described confirming the design and techniques to be simple, reliable and reproducible. Often the tricks of the trade go unpublished and each new surgeon is left to his own learning curve with new devices. As with any surgical instrumentation there are significant little techniques that often make surgery more reproducible and enjoyable. Surgical technique should be simple and reproducible. We have found that even simple procedures—such as head resection—can, and do, impact the surgical process and can affect surgical outcome. Canal reaming, flute engagement, conical reaming, broaching, trochanter clearance, proper use of modular trials and implant assembly all play critical roles to a successful outcome. We have found, and previously reported, that the use of this proximal modular stem design has reduced our leg length inequalities +/− 5 mm and has all but eliminated dislocations and aseptic loosening. There were some mechanical failure problems (previously reported) on the first generation modular junction design that was identified and corrected (never exported outside the U.S.). There have been no reported failures since introduction of the improved modular junction six years ago. Independent selection of femoral offset and vertical height is possible and we feel that restoration of joint mechanics is more reproducible with proximal modular devices as compared to monoblock stems. It is the responsibility of surgeons to communicate their understanding and experience with newer devices and not rely on industry to fill this function.
Hip fracture is a common cause of hospital admission and is often followed by reduced quality of life, or by death. International experiences indicate there are many benefits to be gained from national hip fracture registries. This pilot project aims to implement a hip fracture registry at three sites, a large metropolitan public hospital (Flinders Medical Centre), a large metropolitan private hospital (Epworth HealthCare) and a rural regional hospital (Goulburn Valley Health) to assess the feasibility of establishing a national registry. Patients undergoing surgery for a hip fracture will be recruited from the three participating hospitals between March and September 2009. A minimum data set will be collected at discharge, from hospital records. Items include patient demographics, fracture descriptors, length of stay, residential status, mobility, health status, surgical details and discharge destination. A phone interview at four months after surgery will measure outcomes by using the Extended Glasgow Outcomes Scale and documenting residential status, mobility, hip pain and readmissions. Re- operations, if any, will be collected. The availability of data from State Health Departments for validation of hospital case data will be reported. The pilot study is in progress at the time of writing. Ethical approval has been obtained, data collection, transmission and storage systems have been developed and deployed, and case data collection is underway. Case data will be summarised to describe hip fracture at the participating hospitals. Analysis will review the data elements in the pilot data set and assess their priority for inclusion in a national register—taking account of the quality of the data obtained and the time and other resources required for their collection. We will also evaluate the four-month review process. Any potential obstacles to a national registry that are identified during the pilot will be described and ways to overcome them will be proposed. A national hip fracture registry will improve the quality of care and safety of patients following hip fracture by developing an efficient mechanism to compare and improve the effectiveness of acute health care delivery by all hospitals involved in the management of hip fractures.
To-date neck-sparing stems have been disappointing in their ability to maintain the calcar. A new approach was undertaken to improve load transfer and to create a tissue-sparing stem that would be simple in design, reproducible in technique and provide for fine-tuning joint mechanics while maintaining compressive loads to the calcar.
A modular neck provides for fine-tuning joint mechanics.
Bone and Tissue sparring Restoration of joint mechanics Minimal blood loss Potential reduction in rehabilitation Ease of revision Simple surgical technique Options for bearing surface Selection of femoral head diameter Standard surgical approach to the hip We are encouraged and believe there are advantages in the concept of neck sparing stems. Clinical/surgical evaluation is now underway and will be reported on in the future.
To assess the cost involved and whether orthopaedic patients with Methicillin-resistant Staphylcoccus aureus (MRSA) infections were being managed according to national guidelines, retrospective survey of all MRSA infections over a 26 months period was performed. Demographic details and risk factors were identified. Infection control measures were compared with national guidelines. Total length of hospital stays, treatments received and cost were noted. In total, 78 patients were diagnosed with a MRSA infection (31 male and 47 female) with a mean age 66.4 years +/− 20.8 SD. MRSA infections occurred in 75 (97%) trauma patients and in 2 (3%) elective patients. MRSA infections were isolated from wounds in 62 patients, others sites include sputum, blood, urine and skin colonization. The average time of diagnosis after admission was 20.6 days +/− 16.6 SD. Major risk factors were internal fixation of fractures (97%), previous antibiotics (97%), nursing home residents and hospital transfers (50%). Normal national guidelines were followed in 86% of the cases. Antibiotics were used in 67 patients after microbiological confirmation; this additional cost exceeded £19,000. The mean hospital stay was 50.7 days and the cost of hospitalization per patients exceeded £19,700 (£388.60 per day). Incidence of MRSA infection in trauma and elective patients were 2.4% and 0.1% respectively. Infection control policies were strictly followed in 86% of the cases. Long hospitalization and antibiotics were a significant risk factor for developing MRSA infections. Considering the low incidence of MRSA infection in elective surgery, segregation of trauma and elective patients is an important measure in reducing the incidence and cost of MRSA infections. Substantial saving can be achieved with firmer antibiotics policies.
Patients who undergo total knee replacement (TKR)are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis.
