Background

Smoking has been associated with poor tissue oxygenation and vascularisation, predisposing smokers to a higher risk for postsurgical infections. The aim of this study was to estimate and compare the incidence of prosthetic joint infection (PJI) following primary total joint arthroplasty (TJA) according to smoking status.

Large-head metal-on-metal (MoM) total hip replacements (THR) have given rise to concern. Comparative studies of small-head MoM THRs over a longer follow-up period are lacking. Our objective was to compare the incidence of complications such as infection, dislocation, revision, adverse local tissue reactions, mortality and radiological and clinical outcomes in small-head (28 mm) MoM and ceramic-on-polyethylene (CoP) THRs up to 12 years post-operatively.

A prospective cohort study included 3341 THRs in 2714 patients. The mean age was 69.1 years (range 24 to 98) and 1848 (55.3%) were performed in women, with a mean follow-up of 115 months (18 to 201). There were 883 MoM and 2458 CoP bearings. Crude incidence rates (cases/1000 person-years) were: infection 1.3 vs 0.8; dislocation 3.3 vs 3.1 and all-cause revision 4.3 vs 2.2, respectively. There was a significantly higher revision rate after ten years (adjusted hazard ratio 9.4; 95% CI 2.6 to 33.6) in the MoM group, and ten of 26 patients presented with an adverse local tissue reaction at revision. No differences in mortality, osteolysis or clinical outcome were seen.

In conclusion, we found similar results for small-head MoM and CoP bearings up to ten years post-operatively, but after ten years MoM THRs had a higher risk of all-cause revision. Furthermore, the presence of an adverse response to metal debris seen in the small-head MOM group at revision is a cause for concern.

Cite this article: Bone Joint J 2014; 96-B:868–75.

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement.

We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

Cite this article: Bone Joint J 2014;96-B:390–4.

There are no recent studies comparing cable with wire for the fixation of osteotomies or fractures in total hip replacement (THR). Our objective was to evaluate the five-year clinical and radiological outcomes and complication rates of the two techniques. We undertook a review including all primary and revision THRs performed in one hospital between 1996 and 2005 using cable or wire fixation. Clinical and radiological evaluation was performed five years post-operatively. Cables were used in 51 THRs and wires in 126, and of these, 36 THRs with cable (71%) and 101 with wire (80%) were evaluated at follow-up. The five-year radiographs available for 33 cable and 91 wire THRs revealed rates of breakage of fixation of 12 of 33 (36%) and 42 of 91 (46%), respectively. With cable there was a significantly higher risk of metal debris (68% vs 9%; adjusted relative risk (RR) 6.6; 95% confidence interval (CI) 3.0 to 14.1), nonunion (36% vs 21%; adjusted RR 2.0; 95% CI 1.0 to 3.9) and osteolysis around the material, acetabulum or femur (61% vs 19%; adjusted RR 3.9; 95% CI 2.3 to 6.5). Cable breakage increased the risk of osteolysis to 83%. There was a trend towards foreign-body reaction and increased infection with cables. Clinical results did not differ between the groups.

In conclusion, we found a higher incidence of complications and a trend towards increased infection and foreign-body reaction with the use of cables.

Introduction

Among patients with ankle osteoarthritis (OA) a post-traumatic origin is much more frequent than among those with knee or hip OA. However, long-term studies evaluating risk factors for the development of OA after ankle fractures are lacking.

Introduction

A recent review of the literature on metal-on-metal total hip arthroplasties (THA) revealed the lack of comparative clinical studies with a sufficient sample size and the inclusion of patient-reported outcomes as well as patient activity levels.

Introduction

Large diameter metal on metal cups have been used in total hip arthroplasty advocating superior results with respect to dislocation rates, range of motion and long term survival. The Durom cup used as part of the Durom hip resurfacing system has been incriminated with poor short term results sometimes correlated to incorrect positioning of either the femoral or acetabular component. Our objective was to evaluate short term results of the Durom cup used in conjunction with standard stems.

Introduction

Orthopaedic surgeons are frequently asked to perform a revision total hip arthroplasty (THA) in patients over 80 years of age. Our objective was to evaluate the outcomes after revision THA in patients 80 years or older and compare them to a cohort of patients less than 80 years of age.

Purpose of the study: The purpose of this retrospective clinical and radiographic study was to analyse the long-term results obtained after Patte’s triple locking procedure for the treatment of anterior instability of the shoulder joint.

Material and methods: A questionnaire was sent to 574 patients who underwent the procedure performed by the same senior operator from 1986 to 2006. Variables studied wer the Walch-Duplay score (with pain score), patient satisfaction, postoperative complications and radiographic aspect.

Results: One hundred fifty patients (26%) responded and sent three radiographs. There were 107 men and 43 women, mean age 28.6±8.7 years (range 16–57). Mean follow-up was 14.6 years (range 2.8–22.6). One hundred seventeen patients (78%) were reviewed with follow-up greater than 10 years. Two patients (1.3%) experienced recurrent anterior instability; no revision was required. The Walch-Duplay scores were excellent or good in 146 patients (97.3%); 53% of patients were pain free; 34% had episodic pain, 9% moderate to mild pain and 4% severe pain. Resumption of sports activity was noted by 85% of patients. Overall, 79% of patients were very satisfied, 18% satisfied, and 3% not satisfied. Postoperative complications (2%) were one case each of infection, transient paresis of the musculocutaeous nerve, and superficial venous thrombosis. There were radiographic signs of an anomaly of the coracoids block in 13 patients (8%); non-union (n=3), lysis (n=4) fracture (n=2), migration (n=1), fracture of the ceramic washer (n=3). The block or washer overhang was noted in 19 patients (12.7%). Centred osteoarthritis was noted in 31% of patients (25% Samilson 1, 4% Samilson 2, 2% Samilson 3). There were two factors associated with long-term degenerative disease: age > 40 at surgery (p=0.02 and block overhang (p< 0.01).

Discussion: Patte’s triple locking procedure is an open procedure for the treatment of anterior shoulder instability. The technique is very minute and specific postoperative rehabilitation is needed. In these conditions, the operation is effective, providing good control of shoulder stability and allowing resumption of sports activities with a low complication rate. This study shows that long-term degenerative disease can be decreased if the patient undergoes surgery before the age of 40 years and if the coracoids block does not overhang.

Background: Among patients undergoing total hip arthroplasty (THA) 24–36% are obese. The most important long-term complication is periprosthetic osteolysis. While patient activity, implant type and quality of fixation are known risk factors for osteolysis, the literature concerning obesity is sparse and controversial. Our objective was to evaluate the influence of obesity on femoral osteolysis five and ten years after primary THA with a cemented stem.

Methods: Prospective cohort study conducted between 1996 and 2003 among patients undergoing THA (uncemented cup, cemented stem, 28mm head and ceramic-polyethylene bearing surface) inserted with a third generation cementing technique. All patients were seen at either five or ten years, with information regarding BMI and activity, and with radiographic follow-up. BMI was evaluated in three and four categories (< 25, 25–29.9 (reference category), 30–34.9 and ≥35 kg/m²). Activity was assessed using the University of California, Los Angeles (UCLA) activity scale (1–10 points). Main outcome was the radiographic assessment of femoral osteolysis. Secondary outcomes were polyethylene wear and revision for aseptic loosening.

Results: We included 503 THAs in 433 patients. Of those 241 THAs (48%) were seen at five years and 262 (52%) at ten years. Osteolytic lesions were identified in forty-four cases, twenty-four in 181 normal weight patients (13.3%), eleven in 205 overweight (5.4%), seven in ninety-six obese class I (7.3%), and two in twenty-one obese class II patients (9.5%). Activity was highest in normal weight patients (mean UCLA score 5.5, ±2.0) and lowest in patients obese class II (mean UCLA score 4.8, ±1.7). Univariate as well as multivariate logistic regression analysis adjusting for activity, cementing quality, age, and sex did not show an increased risk of osteolysis in obese compared to overweight patients (adjusted OR 1.4, 95% CI 0.6; 3.7). A significantly higher risk was found in normal weight patients (adjusted OR 2.6, 95% CI 1.2; 5.7). Total mean polyethylene wear was significantly lower in obese compared to normal/overweight patients (p=0.024). Revision for aseptic loosening of the stem was necessary in 4 patients (3 normal weight patients and 1 overweight patient).

Conclusions: We did not find an increased risk for femoral osteolysis or revision for aseptic loosening in obese patients five and ten years after primary THA with a cemented stem.

Introduction: An ankle fracture represents the most frequent osseous injury in both the elderly and non-elderly population. To date, only a limited number of retrospective studies have addressed medium-term outcome following ankle Open Reduction and Internal Fixation (ORIF). The purpose of this study was to assess residual pain and functional outcome 10 to 20 years after operative treatment of ankle fractures and to evaluate the incidence of symptomatic and radiographic ankle osteoarthritis (OA).

Methods: We designed a retrospective study including all consecutive patients who underwent ankle ORIF between January 1988 and December 1997 in a University Hospital setting. Pilon and talus fracture as well as pediatric patients were excluded. Patients were seen by two senior residents 10–20 years after their index surgery. Residual pain was measured using the Visual Analog pain Scale. Function and general health status were assessed using the Olerud and Molander Ankle Score, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the 12-item short-form health survey (SF-12). Ankle OA on standard radiographs was scored according to the revised Kellgren and Lawrence (K& L) scale.

Results: 374 patients (56% men) underwent ankle surgery during the defined period. 10% of the patients had a Weber A fracture, 57% a Weber B and 33% a Weber C fracture. Mean age at the time of operation was 42.9 years (+/− 17.1; range 16–86 years). 10–20 years after surgery, 47 patients had died, 126 had left the country and were lost to follow-up, 99 did not respond or refused to participate, and 102 patients were seen at the follow-up visit. These patients did not differ in terms of age, gender distribution, BMI and type of fracture from those who were not seen. The mean duration of follow up was 17.3 years (+/− 3.3). Advanced radiographic OA (K& L grade 3 and 4) was present in 34.3 % of the patients. Symptomatic OA was reported by 34.3 % of the patients (AOFAS pain score < 40). Both clinically symptomatic and radiographic ankle OA was found in 18 patients (17.6%). Function was good in 85% of the cases (total AOFAS hindfoot score between 80 and 100 points; mean total AOFAS hindfoot score 89.9, +/−14.6). The mean Olerud and Molander ankle score was 86.5 (+/−18.7). The general health status (SF-12) was similar to representative values of the general population with a similar mean age.

Conclusion: 10–20 years after operative treatment of an ankle fracture, the incidence of advanced radiographic post-traumatic ankle OA was 35%, symptomatic OA was present in one third of the patients and about one fifth had both. The majority of the patients reported good function.

We conducted a longitudinal study including patients with the same type of primary hybrid total hip replacement and evaluated patient activity and femoral osteolysis at either five or ten years post-operatively. Activity was measured using the University of California, Los Angeles scale. The primary outcome was the radiological assessment of femoral osteolysis. Secondary outcomes were revision of the femoral component for aseptic loosening and the patients’ quality of life. Of 503 hip replacements in 433 patients with a mean age of 67.7 years (30 to 91), 241 (48%) were seen at five and 262 (52%) at ten years post-operatively. Osteolytic lesions were identified in nine of 166 total hip replacements (5.4%) in patients with low activity, 21 of 279 (7.5%) with moderate activity, and 14 of 58 (24.1%) patients with high activity. The risk of osteolysis increased with participation in a greater number of sporting activities. In multivariate logistic regression adjusting for age, gender, body mass index and the inclination angle of the acetabular component, the adjusted odds ratio for osteolysis comparing high vs moderate activity was 3.6 (95% confidence interval 1.6 to 8.3). Stratification for the cementing technique revealed that lower quality cementing increased the effect of high activity on osteolysis. Revision for aseptic loosening was most frequent with high activity. Patients with the highest activity had the best outcome and highest satisfaction.

In conclusion, of patients engaged in high activity, 24% had developed femoral osteolysis five to ten years post-operatively.

Objective: The Morscher press-fit cup is a cementless, porous-coated acetabular component. The objective of this study was to assess clinical and radiological outcomes, patient satisfaction and complications at 10 years.

Methods: Prospective cohort study including all consecutive primary THAs with the Morscher cup operated by multiple surgeons of a University hospital between March 1996 and April 1998. Patients were evaluated at 120 months (±7.2 months) with clinical and radiological follow-up, patient satisfaction and questionnaire assessment, using the Harris Hip Score (HHS), WOMAC and SF-12. Follow-up examination was done by two physicians who had not performed the operations.

Results: 421 THAs were performed in 389 patients (54.6% women; mean age 69.3, range 28–98). In 80% the diagnosis was primary osteoarthritis. All stems were cemented except for 18 patients (4.3%). One-hundred-twenty-two patients (29.0%) had died, 27 (6.4%) were lost-to follow-up, 24 (5.7%) were unable to attend because of poor general health and 27 (6.4%) refused, thus leaving 221 hips, for which 176 x-rays were available.

None of the patients required cup revision for aseptic loosening. Complications included 12 dislocations and 3 deep infections resulting in 2 total revisions. In 3 patients the stem was revised for aseptic loosening at a mean of 63 months. At 10-years the survivorship was 98.6% (95% CI 96.7; 99.4) with endpoint revision for any cause.

Mean total wear was 0.89 mm (±0.5). 32 cups (18.8%) with a cup inclination > 45° had a mean wear of 1.06 mm (±0.5), whereas 138 cups (81.2%) with inclination < 45° had a mean wear of 0.86 mm (±0.5), p=0.036. In 16 cases osteolytic defects around the stem were present. The outcome scores at 10 years were: HHS 85.9 (±14.1), WOMAC pain 70.7 (±24.7), WOMAC function 68.8 (±24.5), SF-12 physical score 40.3 (±9.2) and mental score 47.0 (±10.4). Ninety-four percent of the patients were satisfied or very satisfied.

Conclusions: The Morscher acetabular replacement cup provides excellent results at 10 years. None of the patients had to be revised for aseptic loosening of the cup, patient satisfaction was high, and clinical results were very good.

Objective: Dislocation is a well known complication after total hip arthroplasty (THA), and the second cause of revision surgery. Our objective was to assess the effect of a pre-operative patient education session on the occurrence of hip dislocation within 6 months after primary THA.

Methods: Between 1998 and 2007 we conducted a prospective cohort study at the University Hospital Department of Orthopaedic Surgery including all primary THAs performed via a transgluteal approach and with use of a 28mm diameter head. The preoperative education session was introduced in June 2002 and included advice on muscle strengthening exercises and postoperative restrictions of range of motion as means of preventing dislocation. Main outcome was the incidence of dislocation within 6 months of surgery. The following potentially confounding factors were assessed: age, sex, body mass index, number of co-morbidities, presence of a neurological disorder, history of alcohol abuse, American Society of Anaesthesiologists (ASA) score, diagnosis (primary or secondary osteoarthritis), previous surgery of the hip, surgeon experience, preoperative functional status, pain level, and motion (Harris Hip Score), preoperative general health status (SF-12), and private or public health care insurance (as proxy for socioeconomic status). Multivariable logistic regression was used for adjustment.

Results: 597 patients who underwent 656 THAs between June 2002 and June 2007 participated in the education session, while 1641 patients who underwent 1945 procedures did not. Forty-six dislocations occurred over the study period, 5 (0.8%) in participants and 41 (2.1%) in non-participants (risk difference 1.3%; 95% CI 0.4; 2.3), with the time interval between surgery and dislocation being significantly shorter among participants (0.2 vs. 1.2 months, p=0.016). Preoperative counselling of 77 patients allowed for preventing one dislocation (number needed to treat). Non-participants had a 2.8 times higher risk of dislocation than participants (unadjusted odds ratio 2.80, 95% CI 1.10; 7.13). Adjustment for age, sex, co-morbidities and prior surgery did not change the results (adjusted odds ratio 2.79, 95% CI 1.09; 7.15).

Conclusion: Preoperative patient education reduced the dislocation risk within 6 months after THA, and particularly after the patient had returned home. Other peri-operative benefits from patient education have been reported and should be considered in a cost-effectiveness analysis.