Post-operative complications after total hip or knee replacement can delay recovery, prolong hospitalisation, increase rates of re-admission and, in the most severe cases, lead to long-term disability or even death. In this analysis of pooled data from four large, randomised, phase III clinical trials that compared the oral, direct Factor Xa inhibitor rivaroxaban with subcutaneous enoxaparin for the prevention of venous thromboembolism after total hip or knee replacement (n = 12 729), the incidence of complications, including bleeding and adverse events related to surgery (such as wound infection, wound dehiscence and haemarthrosis) are reported. Interventions and procedures relating to surgery are also compared between the groups. Bleeding events, including excessive wound haematoma and surgical-site bleeding, occurred at similar rates in the rivaroxaban and enoxaparin groups. Over the total study duration, adverse surgical events occurred at a similar rate in the rivaroxaban group compared with the enoxaparin group after total knee replacement (2.26% vs 2.69%, respectively) and total hip replacement (1.48% vs 1.65%, respectively). Blood loss, wound drainage and transfusion requirements were also similar between the two groups. This analysis shows that the incidence of adverse surgical events with rivaroxaban was similar to enoxaparin

Aims

We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls.

Ceramic-on-ceramic bearings in hip replacement have low rates of wear and are increasingly being used in young adults. Our aim was to determine the incidence of audible phenomena or other bearing-related complications. We retrospectively analysed 250 ceramic-on-ceramic hip replacements in 224 patients which had been implanted between April 2000 and December 2007. The mean age of the patients at operation was 44 years (14 to 83) and all the operations were performed using the same surgical technique at a single centre. At a mean follow-up of 59 months (24 to 94), the mean Oxford hip score was 40.89 (11 to 48). There were six revisions, three of which were for impingement-related complications. No patient reported squeaking, but six described grinding or clicking, which was usually associated with deep flexion. No radiological evidence of osteolysis or migration of the components was observed in any hip. The early to mid-term results of contemporary ceramic-on-ceramic hip replacement show promising results with few concerns in terms of noise and squeaking. Positioning of the acetabular component remains critical in regard to the reduction of other impingement-related complications

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome

Objectives. The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out. Patients and Methods. We measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months. Results. There was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group. Conclusion. The X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important. Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:–207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2

Aims. The long-term functional outcome of total hip arthroplasty (THA) performed by trainees is not known. A multicentre retrospective study of 879 THAs was undertaken to investigate any differences in outcome between those performed by trainee surgeons and consultants. . Patients and Methods. A total of 879 patients with a mean age of 69.5 years (37 to 94) were included in the study; 584 THAs (66.4%) were undertaken by consultants, 138 (15.7%) by junior trainees and 148 (16.8%) by senior trainees. Patients were scored using the Harris Hip Score (HHS) pre-operatively and at one, three, five, seven and ten years post-operatively. Surgical outcome, complications and survival were compared between groups. The effect of supervision was determined by comparing supervised and unsupervised trainees. A primary univariate analysis was used to select variables for inclusion in multivariate analysis. . Results. There was no evidence that the grade of the surgeon had a significant effect on the survival of the patients or the rate of revision (p = 0.987 and 0.405, respectively) up to 12 years post-operatively. There was no significant difference in post-operative functional HHS or total HHS among consultants, junior and seniors up to ten years post-operatively (p = 0.401 and 0.331), respectively. There was no significant difference in hospital stay (p = 0.855) between different grades of surgeons. There was no evidence that the level of supervision had an effect on the survival of the patients or the rate of revision (p = 0.837 and 0.203, respectively) up to 12 years post-operatively. There was no significant difference between supervised and unsupervised trainee groups in post-operative functional HHS or total HHS up to ten years post-operatively (p = 0.213 and 0.322, respectively). There was no significant difference in the mean hospital stay between supervised and unsupervised trainees (p = 0.908). . Take home message: This study suggests that when trainees are appropriately supervised, they can obtain results comparable with those of their consultant colleagues when performing THA. Cite this article: Bone Joint J 2016;98-B:301–6

Aims. The aim of this study was a quantitative analysis of a surgeon’s learning curve for scoliosis surgery and the relationship between the surgeon’s experience and post-operative outcomes, which has not been previously well described. Patients and Methods. We have investigated the operating time as a function of the number of patients to determine a specific pattern; we analysed factors affecting the operating time and compared intra- and post-operative outcomes. We analysed 47 consecutive patients undergoing scoliosis surgery performed by a single, non-trained scoliosis surgeon. Operating time was recorded for each of the four parts of the procedures: dissection, placement of pedicle screws, reduction of the deformity and wound closure. Results. The median operating time was 310 minutes (interquartile range 277.5 to 432.5). The pattern showed a continuous decreasing trend in operating time until the patient number reached 23 to 25, after which it stabilised with fewer patient-dependent changes. The operating time was more affected by the patient number (r =- 0.75) than the number of levels fused (r = 0.59). Blood loss (p = 0.016) and length of stay in hospital (p = 0.012) were significantly less after the operating time stabilised. Post-operative functional outcome scores and the rate of complications showed no significant differences. Take home message: We describe a detailed learning curve for scoliosis surgery based on a single surgeon’s practise, providing useful information for novice scoliosis surgeons and for those responsible for training in spinal surgery. Cite this article: Bone Joint J 2016;98-B:679–85

We report patient-reported outcomes and complications associated with contemporary periacetabular osteotomy (PAO) surgery in treating symptomatic acetabular dysplasia and compare these outcomes with total hip arthroplasty (THA) in patients with similar demographic details. Two consecutive cohorts included patients between aged 18 to 40 years who had undergone either PAO (100 hips; 24 male, 76 female) or THA (55 hips; 18 male, 37 female). At a mean follow-up of 5.9 years (2 to 13), there was significant improvement in the modified Harris hip pain (p < 0.001, PAO and p < 0.001, THA), function (p < 0.001, PAO and p = 0.001, THA), and total scores (p < 0.001, PAO and p < 0.001, THA) within each cohort. There were no significant differences in the clinical outcome scores between the groups. Complication rates were low and similar in each cohort (p = 0.68). Similar to THA, contemporary PAO surgery is a clinically effective procedure that improves function and activity levels, provides pain relief and is associated with an acceptable complication rate. Cite this article: Bone Joint J 2015;97-B:1322–7

Aims

Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients.

The April 2015 Foot & Ankle Roundup. 360 . looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

Aims

The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures.

Periprosthetic joint infection (PJI) is a devastating complication for patients and results in greatly increased costs of care for both healthcare providers and patients. More than 15 500 revision hip and knee procedures were recorded in England, Wales and Northern Ireland in 2013, with infection accounting for 13% of revision hip and 23% of revision knee procedures. We report our experience of using antibiotic eluting absorbable calcium sulphate beads in 15 patients (eight men and seven women with a mean age of 64.8 years; 41 to 83) as part of a treatment protocol for PJI in revision arthroplasty. . The mean follow-up was 16 months (12 to 22). We report the outcomes and complications, highlighting the risk of hypercalcaemia which occurred in three patients. We recommend that serum levels of calcium be routinely sought following the implantation of absorbable calcium sulphate beads in orthopaedic surgery. Cite this article: Bone Joint J 2015;97-B:1237–41

Aims. The treatment of late presenting fractures of the lateral humeral condyle in children remains controversial. . Methods. We report on the outcome for 16 children who presented with a fracture of the lateral humeral epicondyle at a mean of 7.4 weeks (3 to 15.6) after injury and were treated surgically. Results. The mean follow-up was four years (1.1 to 8.9), at which time the mean age of the patients was 8.7 years (3.2 to 17.8). . The mean Dhillon functional score improved from 3.3 to 5.6 and the mean overall scores improved from 5.6 to 8.5. . A total of seven patients had a fishtail deformity and eight had partial lateral epiphyseal closure. None had avascular necrosis. MRI showed an abnormal cartilage signal, incongruence of the joint surface and partial premature closure of the lateral physis in four patients. . Discussion. Neither age at the time of injury, the time interval between injury and operation, nor the pre-operative function were correlated with the incidence of complications. . These results support the use of internal fixation for children with a lateral humeral epicondylar fracture with a delayed presentation. Take home message: Open reduction and internal fixation yielded a satisfactory outcome within 16 weeks in children with a lateral humeral epicondylar fracture with a delayed presentation. Cite this article: Bone Joint J 2016;98-B:244–8

Aims

The primary aim of the study was to perform an analysis to identify the cost per quality-adjusted life-year (QALY) of robot-assisted unicompartmental knee arthroplasty (rUKA) relative to manual total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) for patients with isolated medial compartment osteoarthritis (OA) of the knee. Secondary aims were to assess how case volume and length of hospital stay influenced the relative cost per QALY.

If a modular convertible total shoulder system is used as a primary implant for an anatomical total shoulder arthroplasty, failure of the prosthesis or the rotator cuff can be addressed by converting it to a reverse shoulder arthroplasty (RSA), with retention of the humeral stem and glenoid baseplate. This has the potential to reduce morbidity and improve the results. . In a retrospective study of 14 patients (15 shoulders) with a mean age of 70 years (47 to 83) we reviewed the clinical and radiological outcome of converting an anatomical shoulder arthroplasty (ASA) to a RSA using a convertible prosthetic system (SMR system, Lima, San Daniele, Italy). . The mean operating time was 64 minutes (45 to 75). All humeral stems and glenoid baseplates were found to be well-fixed and could be retained. There were no intra-operative or early post-operative complications and no post-operative infection. The mean follow-up was 43 months (21 to 83), by which time the mean visual analogue scale for pain had decreased from 8 pre-operatively to 1, the mean American Shoulder and Elbow Surgeons Score from 12 to 76, the mean Oxford shoulder score from 3 to 39, the mean Western Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and the mean Subjective shoulder value from 15 to 61. On radiological review, one patient had a lucency around the humeral stem, two had stress shielding. There were no fatigue fractures of the acromion but four cases of grade 1 scapular notching. . The use of a convertible prosthetic system to revise a failed ASA reduces morbidity and minimises the rate of complications. The mid-term clinical and radiological results of this technique are promising. Cite this article: Bone Joint J 2015;97-B:1662–7

Aims

To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon.