Aims

To establish the cost of primary hip (THR) and knee (TKR) arthroplasty in an elective orthopaedic centre in the UK and to compare it with current government reimbursement to NHS hospitals and the costs in North America.

Removal of solidly fixed implants is a challenge in revision knee arthroplasty. It is fraught with the risk of intraoperative fractures and bone stock vital for the success of subsequent revision surgery. We describe the double extraction technique for extraction of solidly fixed implants. This technique was first tested in laboratory setting and then replicated in the operation theatre with successful results.

In this retrospective study we analysed all our patients in which we used the double extraction technique for the removal of solidly fixed implants. In this procedure, the surgeon and the assistant each place an osteotome on the cement metal interface at symmetric positions, directly opposite each other on the medial and lateral sides. They deliver synchronous blows with a mallet at positions around the interface until the cement fractures. The femoral component can then be easily removed. The technique was tested in a laboratory before it was used clinically. Polyurethane mouldings, representing a suitable substrate for cementing metal components were fixed on to a steel rod of similar weight and length as the lower leg. Stainless steel discs (40mm diameter x 4mm thickness) were cemented on to the polyurethane substrate to form a model of a cemented implant. The discs were instrumented to allow recording of the mechanical processes caused by the double extraction technique and to allow comparison with the single osteotome extraction technique. The methodology successfully demonstrated that the double osteotome technique increases the contact force of the second blow. When the synchronous blows are delivered, less energy is expended in the movement of tibia and more is contributed to the removal of the component.

In this study we looked at a total of 206 patients were the solidly fixed tibial and femoral components were removed using the double extraction technique. There were 86 men and 126 women. The mean age of the patients was 66.8 years (range 37–87 years). Only patients with solidly fixed implants were included in this study. Stability of implants was assessed with preoperative radiographs and then confirmed intraoperatively. Patients with loose implants intraoperatively were excluded from this study. We present our results with use of this technique in 206 patients with follow up of 1 to 5 years.

Removal of solidly fixed implants is a challenge in revision knee arthroplasty. It is fraught with the risk of intraoperative fractures and bone stock vital for the success of subsequent revision surgery. We describe the double extraction technique for extraction of solidly fixed implants. This technique was first tested in laboratory setting and then replicated in the operation theatre with successful results.

In this retrospective study we analysed all our patients in which we used the double extraction technique for the removal of solidly fixed implants. In this procedure, the surgeon and the assistant each place an osteotome on the cement metal interface at symmetric positions, directly opposite each other on the medial and lateral sides. They deliver synchronous blows with a mallet at positions around the interface until the cement fractures. The femoral component can then be easily removed. The technique was tested in a laboratory before it was used clinically. Polyurethane mouldings, representing a suitable substrate for cementing metal components were fixed on to a steel rod of similar weight and length as the lower leg. Stainless steel discs (40mm diameter × 4mm thickness) were cemented on to the polyurethane substrate to form a model of a cemented implant. The discs were instrumented to allow recording of the mechanical processes caused by the double extraction technique and to allow comparison with the single osteotome extraction technique. The methodology successfully demonstrated that the double osteotome technique increases the contact force of the second blow. When the synchronous blows are delivered, less energy is expended in the movement of tibia and more is contributed to the removal of the component.

In this study we looked at a total of 206 patients were the solidly fixed tibial and femoral components were removed using the double extraction technique. There were 86 men and 126 women. The mean age of the patients was 66.8 years (range 37–87 years). Only patients with solidly fixed implants were included in this study. Stability of implants was assessed with preopera-tive radiographs and then confirmed intraoperatively. Patients with loose implants intraoperatively were excluded from this study. We present our results with use of this technique in 206 patients with follow up of 1 to 5 years.

Aim: Our aim was to determine the in-hospital costs of total hip replacement (THR) and total knee replacement (TKR), and compare them to their reimbursement under the national tariff system and to our North American colleagues.

Methods: In 2004 an elective orthopaedic centre was set up in South West London which performs mainly primary lower limb arthroplasty. We used a retrospective analysis of financial statements from September 2004- December 2005 inclusive to establish operative costs (including implant), perioperative costs and post operative costs until discharge.

Results: A consecutive series of 1538 primary TKR patients (mean age = 72.2) and 1118 primary THR patients (mean age = 70.8) was studied from September 2004 to December 2005 accounting for 88% of the workload. Average post operative stay was 6.5 days for TKRs and 5.7 for THRs and 66% of the patients were ASA grade III or over. The cost including implant of a THR was £6054, and for a TKR it was £6499. After adjustment to allow direct comparison to tariff, our THR cost is 2.3% less than and 1.0% more than the 2004/5 and 2005/6 tariffs respectively. Our adjusted TKR cost is 5.0 % and 4.2% less than the 2004/5 and 2005/6 tariffs respectively. Our cemented and uncemented THR costs are 8.0% less than and 6.6% more than their respective tariffs introduced for the first time in 2005/6. Overall there is no large discrepancy between our THR/TKR costs and tariff reimbursements.

Discussion: Although in our unit our costs are similar to the re-imbursements used in the UK, we question the ability of general NHS hospitals in the UK to perform at these levels and prices for three reasons. Firstly, our high volume of joint replacement activity has enabled us to negotiate the most favourable implant prices in the UK. Secondly, length of stay in our unit is approximately 60% of national average. Thirdly, our unit is run without many of the infrastructure costs of a general hospital as well as the cost incurred by training junior staff and research and development. Costs were also found to be favourable compared with our American colleagues and similar to our Canadian colleagues.

Conclusion: Our elective only orthopaedic centre provides a cost effect way of performing primary arthroplasty surgery while maintaining high standards of care and twenty-four hour intensive care cover. We believe this cost effectiveness may be unachievable in general NHS hospitals in the UK.

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment.

We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104).

All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70.

Most techniques described for the correction of hallux valgus require exposure of the distal aspect of the first metatarsal. A dorsomedial incision is often recommended. Texts counsel against damaging the dorsal digital nerve, as a painful neuroma is an unwelcome surgical complication.

Our study on cadavers aimed to investigate the anatomy of the dorsomedial cutaneous nerve in the metatarsophalangeal region, with special reference to surgical incisions. A constant, previously unrecognised branch of the nerve was identified. This branch is likely to be damaged if a dorsomedial approach is used. It is recommended that a mid-medial incision be used instead, i.e. at the junction of the plantar and dorsal skin.