Aims
Unicompartmental knee arthroplasty (UKA) has been successfully performed in the United States healthcare system on outpatients. Despite differences in healthcare structure and financial environment, we hypothesised that it would be feasible to replicate this success and perform UKA with safe day of surgery discharge within the NHS, in the United Kingdom. This has not been reported in any other United Kingdom centres.
Patients and Methods
We report our experience of implementing a pathway to allow safe day of surgery discharge following UKA. Data were prospectively collected on 72 patients who underwent UKA as a day case between December 2011 and September 2015.
This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years.
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There is little evidence on the cost effectiveness of different brands of hip prostheses. We compared lifetime cost effectiveness of frequently used brands within types of prosthesis including cemented (Exeter V40 Contemporary, Exeter V40 Duration and Exeter V40 Elite Plus Ogee), cementless (Corail Pinnacle, Accolade Trident, and Taperloc Exceed) and hybrid (Exeter V40 Trilogy, Exeter V40 Trident, and CPT Trilogy). We used data from three linked English national databases to estimate the lifetime risk of revision, quality-adjusted life years (QALYs) and cost.
For women with osteoarthritis aged 70 years, the Exeter V40 Elite Plus Ogee had the lowest risk of revision (5.9% revision risk, 9.0 QALYs) and the CPT Trilogy had the highest QALYs (10.9% revision risk, 9.3 QALYs). Compared with the Corail Pinnacle (9.3% revision risk, 9.22 QALYs), the most commonly used brand, and assuming a willingness-to-pay of £20 000 per QALY gain, the CPT Trilogy is most cost effective, with an incremental net monetary benefit of £876. Differences in cost effectiveness between the hybrid CPT Trilogy and Exeter V40 Trident and the cementless Corail Pinnacle and Taperloc Exceed were small, and a cautious interpretation is required, given the limitations of the available information.
However, it is unlikely that cemented brands are among the most cost effective. Similar patterns of results were observed for men and other ages. The gain in quality of life after total hip arthroplasty, rather than the risk of revision, was the main driver of cost effectiveness.
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The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation.
In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group.
Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation.
The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used.
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The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions.
In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.
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Hip fracture is a global public health problem. The National Hip Fracture Database provides a framework for service evaluation in this group of patients in the United Kingdom, but does not collect patient-reported outcome data and is unable to provide meaningful data about the recovery of quality of life.
We report one-year patient-reported outcomes of a prospective cohort of patients treated at a single major trauma centre in the United Kingdom who sustained a hip fracture between January 2012 and March 2014.
There was an initial marked decline in quality of life from baseline measured using the EuroQol 5 Dimensions score (EQ-5D). It was followed by a significant improvement to 120 days for all patients. Although their quality of life improved during the year after the fracture, it was still significantly lower than before injury irrespective of age group or cognitive impairment (mean reduction EQ-5D 0.22; 95% confidence interval (CI) 0.17 to 0.26). There was strong evidence that quality of life was lower for patients with cognitive impairment. There was a mean reduction in EQ-5D of 0.28 (95% CI 0.22 to 0.35) in patients < 80 years of age. This difference was consistent (and fixed) throughout follow-up. Quality of life does not improve significantly during recovery from hip fracture in patients over 80 years of age (p = 0.928). Secondary measures of function showed similar trends.
Hip fracture marks a step down in the quality of life of a patient: it accounts for approximately 0.22 disability adjusted life years in the first year after fracture. This is equivalent to serious neurological conditions for which extensive funding for research and treatment is made available.
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Aims
The aim of this study was to investigate the outcomes of Vancouver type B2 and B3 fractures by performing a systematic review of the methods of surgical treatment which have been reported.
Materials and Methods
A systematic search was performed in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. For inclusion, studies required a minimum of ten patients with a Vancouver type B2 and/or ten patients with a Vancouver type B3 fracture, a minimum mean follow-up of two years and outcomes which were matched to the type of fracture. Studies were also required to report the rate of re-operation as an outcome measure. The protocol was registered in the PROSPERO database.
Aims
The aim of this study was to compare early functional and health related quality of life outcomes (HRQoL) in patients who have undergone total hip arthroplasty (THA) using a bone conserving short stem femoral component and those in whom a conventional length uncemented component was used. Outcome was assessed using a validated performance based outcome instrument as well as patient reported outcome measures (PROMs).
Patients and Methods
We prospectively analysed 33 patients whose THA involved a contemporary proximally porous coated tapered short stem femoral component and 53 patients with a standard conventional femoral component, at a minimum follow-up of two years. The mean follow-up was 31.4 months (24 to 39). Patients with poor proximal femoral bone quality were excluded. The mean age of the patients was 66.6 years (59 to 77) and the mean body mass index was 30.2 kg/m2 (24.1 to 41.0). Outcome was assessed using the Oxford Hip Score (OHS) and the University College Hospital (UCH) hip score which is a validated performance based instrument. HRQoL was assessed using the EuroQol 5D (EQ-5D).
Aims
Our aim was to examine the clinical and radiographic outcomes in 257 consecutive Oxford unicompartmental knee arthroplasties (OUKAs) (238 patients), five years post-operatively.
Patients and Methods
A retrospective evaluation was undertaken of patients treated between April 2008 and October 2010 in a regional centre by two non-designing surgeons with no previous experience of UKAs. The Oxford Knee Scores (OKSs) were recorded and fluoroscopically aligned radiographs were assessed post-operatively at one and five years.
Aims
The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.
Patients and Methods
A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS).
The aim of this study was to examine the rates
and potential risk factors for 28-day re-admission following a fracture
of the hip at a high-volume tertiary care hospital. We retrospectively
reviewed 467 consecutive patients with a fracture of the hip treated
in the course of one year. Causes and risk factors for unplanned
28-day re-admissions were examined using univariate and multivariate
analysis, including the difference in one-year mortality. A total
of 55 patients (11.8%) were re-admitted within 28 days of discharge.
The most common causes were pneumonia in 15 patients (27.3%), dehydration
and renal dysfunction in ten (18.2%) and deteriorating mobility
in ten (18.2%). A moderate correlation was found between chest infection
during the initial admission and subsequent re-admission with pneumonia
(r = 0.44, p <
0.001). A significantly higher mortality rate
at one year was seen in the re-admission group (41.8% (23 of 55)
Periprosthetic femoral fracture (PFF) is a potentially devastating complication after total hip arthroplasty, with historically high rates of complication and failure because of the technical challenges of surgery, as well as the prevalence of advanced age and comorbidity in the patients at risk.
This study describes the short-term outcome after revision arthroplasty using a modular, titanium, tapered, conical stem for PFF in a series of 38 fractures in 37 patients.
The mean age of the cohort was 77 years (47 to 96). A total of 27 patients had an American Society of Anesthesiologists grade of at least 3. At a mean follow-up of 35 months (4 to 66) the mean Oxford Hip Score (OHS) was 35 (15 to 48) and comorbidity was significantly associated with a poorer OHS. All fractures united and no stem needed to be revised. Three hips in three patients required further surgery for infection, recurrent PFF and recurrent dislocation and three other patients required closed manipulation for a single dislocation. One stem subsided more than 5 mm but then stabilised and required no further intervention.
In this series, a modular, tapered, conical stem provided a versatile reconstruction solution with a low rate of complications.
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It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery.
Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb.
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Concerns have been reported to the United Kingdom National Patient Safety Agency, warning that cementing the femoral component during hip replacement surgery for fracture of the proximal femur may increase peri-operative mortality.
The National Hip Fracture Database collects demographic and outcome data about patients with a fracture of the proximal femur from over 100 participating hospitals in the United Kingdom. We conducted a mixed effects logistic regression analysis of this dataset to determine whether peri-operative mortality was increased in patients who had undergone either hemiarthroplasty or total hip replacement using a cemented femoral component. A total of 16 496 patients from 129 hospitals were included in the analysis, which showed a small but significant adjusted survival benefit associated with cementing (odds ratio 0.83, 95% confidence interval 0.72 to 0.96). Other statistically significant variables in predicting death at discharge, listed in order of magnitude of effect, were gender, American Society of Anesthesiologists grade, age, walking accompanied outdoors and arthroplasty. Interaction terms between cementing and these other variables were sequentially added to, but did not improve, the model.
This study has not shown an increase in peri-operative mortality as a result of cementing the femoral component in patients requiring hip replacement following fracture of the proximal femur.
Objectives
A possible solution for the management of proximal femoral bone loss is a modular femoral endoprosthesis (EPR). Although the outcome of EPRs in tumour surgery has been well described, the outcome of their use in revision hip surgery has received less attention. The aim of this study was to describe the outcome of using EPR for non-neoplastic indications.
Methods
A retrospective review of 79 patients who underwent 80 EPRs for non-neoplastic indications was performed, including the rates of complication and survival and the mean Oxford Hip Scores (OHS), at a mean of five years post-operatively. The mean age at the time of surgery was 69 years (28 to 93) and the mean number of previous operations on the hip was 2.4 (0 to 17). The most common indications for EPR implantation were periprosthetic joint infection (PJI) (n = 40), periprosthetic fracture (n = 12) and failed osteosynthesis of a proximal femoral fracture or complex trauma (n = 11).
Modern metal-on-metal hip resurfacing has been widely performed in the United Kingdom for over a decade. However, the literature reports conflicting views of the benefits: excellent medium- to long-term results with some brands in specific subgroups, but high failure rates and local soft-tissue reactions in others. The National Joint Registry for England and Wales (NJR) has collected data on all hip resurfacings performed since 2003. This retrospective cohort study recorded survival time to revision from a resurfacing procedure, exploring risk factors independently associated with failure. All patients with a primary diagnosis of osteoarthritis who underwent resurfacing between 2003 and 2010 were included in the analyses. Cox’s proportional hazard models were used to analyse the extent to which the risk of revision was related to patient, surgeon and implant covariates.
A total of 27 971 hip resurfacings were performed during the study period, of which 1003 (3.59%) underwent revision surgery. In the final adjusted model, we found that women were at greater risk of revision than men (hazard ratio (HR) = 1.30, p = 0.007), but the risk of revision was independent of age. Of the implant-specific predictors, five brands had a significantly greater risk of revision than the Birmingham Hip Resurfacing (BHR) (ASR: HR = 2.82, p < 0.001, Conserve: HR = 2.03, p < 0.001, Cormet: HR = 1.43, p = 0.001, Durom: HR = 1.67, p < 0.001, Recap: HR = 1.58, p = 0.007). Smaller femoral head components were also significantly more likely to require revision (≤ 44 mm: HR = 2.14, p < 0.001, 45 to 47 mm: HR = 1.48, p = 0.001) than medium or large heads, as were operations performed by low-volume surgeons (HR = 1.36, p < 0.001). Once these influences had been removed, in 4873 male patients < 60 years old undergoing resurfacing with a BHR, the five-year estimated risk of revision was 1.59%.
In summary, after adjustment for a range of covariates we found that there were significant differences in the rate of failure between brands and component sizes. Younger male patients had good five-year implant survival when the BHR was used.
We present a comparison of patient-reported outcomes (PROMs) in relation to patient age, in patients who had received a total (TKR) or unicompartmental knee replacement (UKR). The outcome was evaluated using the Oxford knee score (OKS), EuroQol (EQ-5D) and satisfaction scores. Patients aged 65 to 84 years demonstrated better pre-operative function scores than those aged < 65 years (OKS, p = 0.03; EQ-5D, p = 0.048) and those aged ≥ 85 years (OKS, p = 0.03). Post-operative scores were comparable across age groups, but a linear trend for greater post-operative improvement in OKS and EQ-5D was seen with decreasing age (p < 0.033). The overall mean satisfaction score at six months was 84.9, but those aged < 55 years exhibited a lower mean level of satisfaction (78.3) compared with all other age groups (all p < 0.031). The cumulative overall two-year revision rate was 1.3%. This study demonstrates that good early outcomes, as measured by the OKS and EQ-5D, can be anticipated following knee replacement regardless of the patient’s age, although younger patients gain greater improvement. However, the lower satisfaction in those aged < 55 years is a concern, and suggests that outcome is not fully encapsulated by the OKS and EQ-5D evaluation, and raises the question whether the OKS alone is an appropriate measure of pain and function in younger, more active individuals.
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The Nottingham Hip Fracture Score (NHFS) was developed to assess the risk of death following a fracture of the hip, based on pre-operative patient characteristics. We performed an independent validation of the NHFS, assessed the degree of geographical variation that exists between different units within the United Kingdom and attempted to define a NHFS level that is associated with high risk of mortality.
The NHFS was calculated retrospectively for consecutive patients presenting with a fracture of the hip to two hospitals in England. The observed 30-day mortality for each NHFS cohort was compared with that predicted by the NHFS using the Hosmer–Lemeshow test. The distribution of NHFS in the observed group was compared with data from other hospitals in the United Kingdom. The proportion of patients identified as high risk and the mortality within the high risk group were assessed for groups defined using different thresholds for the NHFS.
In all 1079 hip fractures were included in the analysis, with a mean age of 83 years (60 to 105), 284 (26%) male. Overall 30-day mortality was 7.3%. The NHFS was a significant predictor of 30-day mortality. Statistically significant differences in the distribution of the NHFS were present between different units in England (p < 0.001). A NHFS ≥ 6 appears to be an appropriate cut-point to identify patients at high risk of mortality following a fracture of the hip.
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