Purpose

Total and partial joint arthroplasty has been clinically proven to successfully relieve pain and improve function in patients with hip and knee degenerative arthrosis. It has been shown that early return to ambulation correlates well with functional scores. Moreover, the benefits of reduced narcotic use are multi-fold and range from reduced risk of addiction, gastrointenstinal and cardiopulmonary side effects. Establishing realistic pre-operative expectations regarding functional improvement and pain control will nevertheless impact patient satisfaction. Thus, the purpose of this study was to establish safe, achievable and data-driven benchmarks for post-operative ambulation and pain control in patients undergoing elective total joint arthroplasty.

Introduction

Patellar mobilisation methods used during total knee arthroplasty (TKA) have been debated in the literature, with some proponents of minimally invasive TKA suggesting that laterally retracting, rather than everting the patella may be beneficial. It was our hypothesis that by using randomised, prospective, blinded study methods, there would be no significant difference in clinical outcome measures based solely on eversion of the patella during total knee arthroplasty.

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative.

In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200.

Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient.

From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards.

Sixty-three knees with chronic ligamentous instability treated with flexible carbon fibre are reviewed. Assessment was by pre-operative and postoperative grading of function in work and sport, together with a subjective evaluation of the result based on stability. Fifteen knees had collateral repairs, seven had cruciate repairs and 41 had combined collateral and cruciate repairs. Overall, 71% of knees showed improvement in function and 67% had good or excellent results subjectively. Clinical examination did not correlate well with the patient's evaluation of the result. Nineteen unselected cases with intra-articular (cruciate) carbon fibre had arthroscopies. Infiltration of collagen tissues into the cruciate replacement was a slower process than at the extra-articular (collateral) site. There was no clinical or macroscopic evidence of synovitis but microscopically there was evidence of synovial irritation.

Ruptures of the calcaneal tendon which present late may be repaired using carbon fibre to induce a neotendon. The operative technique is described and the results of five cases reviewed. The average muscle power obtained was 88% of normal, and the thickness of the neotendon was 148% of that of the normal side. It would appear that this tendon formation in man is comparable to that previously described in sheep.

The role of flexible carbon-fibre implants as substitutes for injured tendons and ligaments was investigated. These implants were simple to perform and were well tolerated by the patient. Repairs using carbon-fibres in 60 patients were successful, particularly in the almost insoluble problem of posterior cruciate laxity. The results in this report show that carbon-fibre implants have few disadvantages and have a future use in reconstructive procedures.

Carbon fibre appears to induce the formation of tendon in both animals and humans. Experiments have been conducted in sheep in which new anterior cruciate ligaments have been induced in response to the implantation of filamentous carbon fibre. Long-term studies indicate that the carbon fibre slowly breaks up at the site of implantation and later begins to appear in the regional lymph nodes.

The case is reported of an elderly man with asymptomatic cervical spondylosis who sustained a minor hyperextension injury of the cervical spine when the brakes of a car were applied suddenly to avoid a collision. Within six hours marked swelling of the neck and severe dyspnoea developed, and a lateral radiograph showed the pharyngeal shadow displaced far forwards and a crack fracture of an anterior osteophyte. Tracheostomy and evacuation of a massive prevertebral haematoma were performed, with immediate relief. The case draws attention to the possibility of this serious complication of a "whiplash" type of injury.

Experiments have been performed on rabbits and sheep which demonstrate that pure carbon, in a flexible and filamentous form of great strength, can be used successfully to induce the formation of new tendons. A concept fundamentally different from that underlying the use of other artificial tendon replacements is involved, in which rapidly developing tendon-like tissue is induced to form around the implant. This gradually takes over the function of the implant. The early results in rabbits and the late results in sheep suggest that filamentous carbon may have a place in the replacement of the calcaneal tendon and the collateral ligaments of the knee.