Introduction

With the introduction of new technology in orthopaedics, surgeons must balance anticipated benefits in patient outcomes with challenges or complications associated with surgical learning curve for the technology. The purpose of this study was to determine whether the surgeon learning curve with a new multi-radius primary TKA system (primary TKA implant and instruments) designed for surgical team ease would impact clinical outcomes, surgical time and complications.

Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

The majority of hip fracture patients receive operative treatment, although the National Hip Fracture Database (NHFD) 2012 suggest 2.6% were treated conservatively. One of only a few published reports on the outcomes of these patients has demonstrated that mortality rates beyond 30 days remain comparable to patients receiving surgery. We have assessed the outcomes of conservatively managed patients in our unit.

Patients treated conservatively at our hospital between 2010 and 2012 inclusive were identified using the NHFD. Data collection included mobility status, ASA grade, Nottingham Hip Fracture Score (NHFS), mortality (30 days and 1 year) and pain scores.

The study group (N=31) had a mean age 85, mean ASA was 4 and mean NHFS mortality risk 21.3%. Morbidity included one case of pneumonia and one infection from another source, however there were no pressure sores or VTE. Three patients later received surgery once their health had improved. Pain control was achieved in 91% patients (21/23) and although mobility decreased, 34.8% of patients were able to mobilise with either two aids or a frame.

Given the selection bias for conservative treatment in unwell patients, the higher mortality figure is not unexpected. Although the 30 day mortality data is higher than the national average for operative management, those patients surviving 30 days have a mortality similar to those managed operatively. Despite mobility decreasing from the pre-admission status, a significant number of patients were pain free and could mobilise. Therefore conservative management can produce acceptable results in these patients.

We aimed to assess the long term results of patients who underwent Autologous Chondrocyte Implantation (ACI) for osteochondral lesions of the talus. Between 1998 and 2006, 28 patients underwent ACI for osteochondral lesions of the talus. All these patients were prospectively reviewed and assessed for long term results. Outcomes were assessed using satisfaction scores, Mazur ankle score and the AOFAS score, and Lysholm knee score for donor site morbidity.

The 28 patients who underwent the procedure included 18 males and 10 females. Follow up ranged from 1–9 years. In all patients, there was an improvement in the Mazur and AOFAS ankle scores and the Lysholm scores showed minimal donor site morbidity. Improvement in ankle score was independent of age and gender. The better the pre-op score the less the difference in post-op ankle scores. Patients were unlikely to benefit with pre-op ankle scores over 75.

The mid to long term results of ACIs in the treatment of localised, contained cartilage defects of the talus are encouraging and prove that it is a satisfactory treatment modality for symptomatic osteochondral lesions of the talus. Complications are limited. However, in view of limited number of patients, a multi-centre randomised controlled study is required for further assessment.

Background: Tension Band wiring technique is commonly used to treat transverse patella fractures. The commonly used configuration has parallel K wires and a stainless steel wire loop oriented as a figure of 8. Use of non-metallic suture materials as reliable fixation materials have been reported. We investigated the properties of composite polyester suture (Fibre wire) when used in Tension band wiring of patella.

Methods: A wooden model of a transversely fractured patella was used. The fracture was fixed using two K wires and a loop of horizontally oriented stainless steel wire or fibre wire. Two wire twists placed at corners were used for SS wire loops. For fibre wire samples a tensioning device was used and the knots placed at one corner. Interfragmentary compression at the point of wire breakage and fracture displacement on physiologic cyclic loading was measured for each fixation construct. The reliability of tensioning device (Arthrex) and the effect of using multiple strands of wire were assessed.

Results: Use of the tensioning device produced interfragmentary compression that could be repeated reliably. The addition of a further strand increased the interfragmentary compression developed by 94%. There was no significant difference between interfragmentary compression developed between groups (p> 0.05). The average interfragmentary compression produced for three repetitions for the individual groups, Fibre wire (1394N), SS wire of 1.0mm diameter (1320N), SS Wire of 1.25mm diameter (1594N) were comparable. This increased significantly when a second loop of fibre wire was used (2566N). Permanent fracture displacement at physiologic loads were, Fibre wire (9.7mm, SD 2.7mm), SS wire of 1.0mm diameter (7.0mm, SD 1.0mm) and SS Wire of 1.25mm diameter (7.4mm, SD 2.3mm). The addition of the second strand of fibre wire decreased the displacement significantly (4.8mm, SD 0.6mm). The effect of second strand of fibre wire decreased the displacement by 97% while the decrease on addition of the second strand of stainless steel wire was only 14%.

Discussion: Interfragmentary compression produced to failure was comparable between a single strand of fibre wire, 1.0mm SS wire and 1.25mm SS wire, the commonly used SS wire diameters in fixation of fractured patella. The standard deviations of final permanent displacement were higher with the larger diameter of SS wire, indicating that the use of a thicker wire would require some preloading before it is uniformly tensioned. Amongst the SS wire diameters tested, 1.0mm resulted in least variations (SD 1.0mm).

The addition of second strand resulted in a marked improvement in displacement with Fibre wire and variations between different samples were smaller than in any other group tested (SD 0.6mm)

Conclusions:

Fibre wire has similar strength to failure when compared the commonly used thickness of stainless steel wire for fixation of patella.

Statement of Purpose We describe the donor site morbidity of hyaline cartilage biopsy from the trochlea of the knee when used for ACI in the ankle joint.

Methods We studied 12 patients who received a two stage ACI procedure on the talus, performed by three consultant surgeons. The first stage involved knee arthroscopy and harvest of cartilage for culture and stage two the transplantation of a chondrocyte culture to the ankle joint.

During the first stage knee arthroscopy using a superolateral approach, the cartilage specimens were taken from a minor load bearing area of either the central or superolateral trochlea using a 5mm gouge.

Clinical outcomes were assessed using a patient satisfaction score and the Lysholm knee score, taken both pre- and post- operatively at 3 months and annually thereafter.

Results The mean age of the patient group was 42. The patient satisfaction questionnaires showed 11 patients to be ‘pleased’ or ‘extremely pleased’ with their ACI procedure which was sustained in the patients with up to four years follow up.

The mean Lysholm score preoperatively was 98/100. Postoperatively eight patients had a reduced score (mean reduction 14) at twelve months follow up. In those patients with new knee symptoms at one year, analysis of the Lysholm score components showed the Locking and Limp categories to be the most frequent cause of a reduced score. Two patients had repeat knee arthroscopy at 18 months and 2 years postoperatively for symptoms of catching, anterior knee pain and swelling.

Discussion The Lysholm knee score has components which may be affected by ipsilateral joint problems, which contribute to 20% of the overall score. However those patients with an abnormal Lysholm knee score postoperatively have gained an improved Mazur ankle score since their ACI.

The procedure of cartilage harvest from the trochlea of the knee has an associated donor site morbidity which is present at one year. Ninety two percent of patients were pleased or extremely pleased with their ACI procedure, despite the requirement of surgery on their knee and it would seem that the amount of early knee morbidity these patients experience is outweighed by the improvement in symptoms in the treated joint.

Ideally to optimise cartilage repair less morbid techniques to obtain cartilage need to be identified or alternatively mesenchymal stem cells could be used as an alternative source, which has already had limited success in the knee and might also be applied to other joints.

Aim: To review the early complications associated with staged revision hip Arthroplasty utilising the Biomet antibiotic loaded cement spacer.

Method: We report on 80 consecutive staged revision hip replacements using the Biomet antibiotic loaded cement system in our institution over 3 years (1999–2002), performed by three consultant surgeons, with a minimum 1 year follow up.

Results: Our patients had an average age of 68 (range 48–90) years, with an equal sex distribution.

The median time between the first and second stage was 147 (range 50–619) days.

Fractures of the Biomet antibiotic loaded acrylic spacer occurred in 11% revisions when associated with an increase in time between stages and there was a 7% dislocation rate.

Patients did not receive a revision prosthesis in 19% cases and had early recurrent sepsis following their two stage procedure in 6%. Three patients had a single episode of dislocation of their revision hip prosthesis within a month postoperatively. Two patients had a proximal DVT and one patient had a pulmonary embolus. The mortality within eight weeks was 7%, rising to 10% within a year. This may be related to patient sepsis and comorbidities or the energy expenditure required to mobilise following a first stage procedure that we have analysed.

Conclusions: The risks of staged revision hip surgery for infection are substantial when considering the time involved, the energy expenditure required to mobilise following a first stage, the possibility of not achieving a revision hip prosthesis and the mortality rate.

The Biomet antibiotic loaded cement system articulates and maintains soft tissue length in the majority of patients for the duration required between stages.

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was ‘pleased’ or ‘extremely pleased’, which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.

Patients with osteochondral lesions of the talus have traditionally been difficult to treat. Autologous chondrocyte implantion (ACI) may provide predictable repair through restoring an articular surface. We reviewed our results of Ankle ACI in eight ACI plus two ACI and mosaicplasty combined with an average age of 40 years (32 to 62) performed over four years.

The patients were assessed with a modified Mazur ankle score, patient satisfaction score and Lysholm knee score, pre- and post-operatively. Ankle arthroscopic assessment was performed in patients at 12 months post surgery. The average time to follow up was 24 months (range two to 52). The osteochondral lesions were post traumatic in seven cases, with seven lesions situated medially and three anterolaterally. The average size of the talar defects at surgery was 2.25cm (range 1 to 4 cm.)

Patient satisfaction scores in eight patients were either “extremely pleased” or “pleased” with the operation which was sustained in the patients at up to four years follow up. The Mazur scores increased by 23 points at mean 24 months follow up. Six patients with over 12 months follow up maintained a markedly improved ankle score. Patients were noted to rehabilitate twice as quickly as patients receiving ACI to the knee.

The Lysholm knee scores returned to the preoperative level in four patients, with the remaining six patients showing a reduced score (mean 12 points), suggesting there may be some donor site morbidity. Five had ankle arthroscopy at one year and were shown to have filled defects and stable cartilage. A biopsy taken from the graft site showed hyaline like cartilage and fibrocartilage to be present These early results suggest that ankle ACI is an appropriate treatment for large symptomatic osteochondral lesions in the talus.