What are the Predictors for Bead Shedding in Porous-Coated Hip and Knee Arthroplasties? : An Implant Retrieval Study

Bead shedding has been reported in both hip and knee arthroplasties and can result in increased polyethylene wear and metal ion release. The rates of bead loss were recorded for each device type, and the interfacial bead-substrate shear load to failure and contact areas of the beads were determined. The 3 components with the highest rate of bead loss, namely, S-Rom, Omnifit, and Optifix acetabular shells, recorded the lowest shear loads to failure. Percentage bead-substrate contact area ranged between 7% and 37% and was the most important factor affecting bead shedding. Other factors influencing bead loss in decreasing order of importance were bead fusion, bead size, component type (acetabular or knee), component loosening, and time in situ.     

Age-Dependent Fracture Risk in Hip Revisions With Radial Impaction Grafting Technique : A 5–10 Year Medium-Term Follow-Up Study

Radial impaction grafting (RIG) potentially improves the durability and reliability of cementing the femoral components in revision total hip arthroplasty (THA). In this multicenter, prospective study, 88 revision THAs (87 patients) with RIG technique were performed. The average follow-up time was 7.0 years (range, 5.0–10.2). There were 14 femur fractures: 2 intraoperative, 5 within 3 months after surgery, and 7 later in the postoperative stage (range, 5–84 months). Sixteen patients were lost to follow-up and 20 died without stem re-revision. None of the patients have been re-revised for any reason during follow-up. Age was observed to be a significant factor for determining fracture risk. In conclusion, RIG can be considered a reliable surgical technique, especially for younger patients.     

Hip Resurfacing in an 88-Year-Old Patient? : Highlighting Selection Criteria for Hip Resurfacings in Patients Older than 65 Years

The success of hip resurfacings in the older population is still to be determined, although it has been an attractive option in the much younger patients with arthrosis of the hip. We present a 95-year-old active, independent patient who underwent a Birmingham hip resurfacing at 88 years of age. More than 7 years after surgery, the original components are still in situ, and the patient is pain-free with a very active lifestyle at the age of 95 years. Hip resurfacings are not without risks, and we highlight the evolution of strict selection criteria for patients older than 65 years who may be suitable candidates for hip resurfacing arthroplasty.     

Early Return to Function After Hip Resurfacing : Is It Better Than Contemporary Total Hip Arthroplasty?

Our hypothesis was that return of function for young patients undergoing resurfacing total hip arthroplasty (THA) with metal-on-metal bearings or contemporary THA with ceramic bearings would be comparable. Results from 337 unilateral hip resurfacing patients were compared with results from 266 unilateral ceramic-on-ceramic THA patients. Early differences in Harris Hip Scores were observed, but all differences faded by 24 months. Hip resurfacing seems to be a viable alternative to THA for well-selected patients. However, the public perception of improved functional capabilities was not demonstrated in this patient population. Resurfacing patients may be more impaired (slightly higher pain scores/lower function scores) than their THA counterparts in the early postoperative period, but these differences disappear by 24 months when both groups report Harris Hip Scores in the excellent range.     

Optimization of Total Hip Arthroplasty Implantation : Is the Anterior Pelvic Plane Concept Valid?

The anterior pelvic plane (APP) is currently used as superficial anatomical landmark for three-dimensional orientation during total hip arthroplasty (THA), specifically when using computer aided surgery. However, the actual parameter for characterizing the pelvic orientation is the sacral slope, which correlates with other functional spinal parameters. The goal of the paper was to investigate relationships between APP and sacral slope. Both were measured on 328 lateral radiographs of the pelvis in standing position by two observers. The poor correlation between APP and sacral slope suggest keeping using the reference to the APP for the per-operative orientation in the 3D space, while individually adjusting the preoperative planning to the sacral slope.     

Repeat 2-Stage Exchange for Infected Total Hip Arthroplasty : A Viable Option?

We investigated whether performing a repeat 2-stage exchange eradicates infection in patients who previously underwent 2-stage treatment for an infected total hip arthroplasty. We identified 15 patients who had failed a 2-stage total hip arthroplasty and underwent a planned repeat 2-stage between 2000 and 2009. Of the 15 patients, 8 were treated with a complete 2-stage procedure, whereas the remaining 7 patients were treated only with a first-stage resection of the infected implant. Of the 8 patients who underwent complete 2-stage exchange, 1 died because of in-hospital complications, and 1 had a recurrent infection. Repeat infection is highly associated with resistant organisms, obesity, and poor patient health. Of the 7 patients who underwent resection without reimplantation, 3 had a recurrent infection. Our data suggest that if infection can be adequately controlled after repeat resection of the joint prosthesis, reimplantation is a reasonable option.     

Recovery Room Radiographs After Total Hip Arthroplasty : Tradition vs Utility?

Routine inpatient radiographs after total hip arthroplasty can be taken in the recovery room immediately after surgery or in the radiology suite later in the hospital stay. In a review of 632 consecutive recovery room series, we found that 17% of series were inadequate to detect technical issues. We identified technical issues on 12 series (1.9%) and technical issues that impacted inpatient management on 2 series (0.3%). One of these 2 was a dislocation that was detected clinically before imaging. The other was a medial penetration of an acetabular screw that probably did not require the immediate revision that it received. Findings suggest that the single routine inpatient series should be taken in the radiology suite, rather than in the recovery room.     

Is Second Generation Metal-On-Metal Primary Total Hip Arthroplasty With a 28 mm Head a Worthy Option? : A 12- to 18-Year Follow-Up Study

To determine whether MoM THA with a small head is still worthy of use, we investigated survivorship, complications, and factors influencing failure. Of 149 consecutive patients (195 hips), 141 (180 hips) of mean age 43 (19–55) years were available for review at a mean of 14.4 years postoperatively. Survivorship for cup revision for any cause was 97.8% at 18.4 years postoperatively. Nine hips generated complaints of groin pain; six showed periacetabular osteolysis, one had pain without radiological change, and two were diagnosed as symptomatic pseudotumors. Four of six hips with periacetabular osteolysis or aseptic loosening were revised. Surgery- and patient-related factors had no effect in results. Our results are encouraging, however, further study will be necessary to determine the incidence and fates of pseudotumors after MoM THA with a small head.     

Factors Influencing Revision Risk Following 15 740 Single-Brand Hybrid Hip Arthroplasties : A Cohort Study From a National Joint Registry

This retrospective cohort study of a National Joint Registry data examines survival time to revision following the commonest brand of primary hybrid THA, exploring risk factors independently associated with failure. Overall 5-year revision was 1.56%. In the final adjusted model, revision risk was significantly higher with standard polyethylene (PE) liners (metal-on-PE: hazard ratio [HR] = 2.52, P = 0.005, ceramic-on-PE: HR = 2.99, P = 0.025) when compared to metal-on-highly-cross-linked (XL) PE. Risk of revision with ceramic-on-ceramic bearings was borderline significant (HR = 1.86, P = 0.061). A significant interaction between age and acetabular shell type (solid or multi-hole) was found (P = 0.022), suggesting that solid shells performed significantly better in younger patients. In summary, we found that there were significant differences in implant failure between different bearing surfaces and shell types after adjusting for a range of covariates.     

Total Hip Arthroplasty in Patients 50 Years or Less : Do We Improve Activity Profiles?

The primary objective of this study was to use step activity monitoring to quantify activity changes after total hip arthroplasty in patients 50 years or less. Secondly, we investigated whether step activity measurements correlated with the Harris hip and UCLA scores. We prospectively analyzed 37 patients (age ≤ 50) treated with primary THA. Patient activity was recorded with a step activity monitor. Harris hip and UCLA scores were analyzed. Total daily stride counts increased by an average of 30.0%. Increases were noted in the percent of daily time spent at high, moderate and low activity. Increases in daily time spent at high activity moderately correlated with the UCLA activity score but did not correlate with the HHS. Both the UCLA score and the HHS did not correlate with mean daily strides. Following THA, patients ≤ 50 years of age increase their activity by taking more daily strides and improve their activity profile by spending more time at higher activity. Improvements in step activity moderately correlate with improvements in UCLA scores.     

Patellar Management in Revision Total Knee Arthroplasty : Is Patellar Resurfacing a Better Option?

The management of the patella during revision total knee arthroplasty (TKA) depends on the indication for revision, the type and stability of the patellar component in place, and availability of bone stock. We prospectively compared the clinical outcome and satisfaction rates in revision TKA patients managed with patellar resurfacing (n = 13, group I) to retention of the patellar component (n = 22, group II) or patelloplasty (n = 11, group III) at a minimum follow-up of 2 years. There were no differences in the improvement of Knee Society Scores, Short-Form 36 Scores, and satisfaction rates between the groups. There were no revision surgeries for patellar component failure or patellar fractures. Satisfactory results can be achieved using a variety of methods of patellar management in revision TKA by individualizing the treatment modality depending on the clinical scenario.     

Are paediatric burns more common in asylum seekers?: An analysis of paediatric burn admissions

The number of asylum seekers in Ireland has increased dramatically over the last 10 years. Based on our impression that the number of children admitted to our burn unit was disproportionately represented by children of asylum seekers we performed an audit to establish (1) what proportion of admissions are from this subgroup and (2) the characteristics of their burns. All paediatric burn admissions from May 2003 to April 2004 were reviewed. Data collected from a retrospective chart review included patient demographics and details of the burn injuries. The National Census of 2002 and the Office of the Refugee Applications Commissioner were consulted for population statistics. Total burn admissions for the period were 126: Irish nationals (n=107), non-national residents (n=2), asylum seekers (n=14) and patients of unknown asylum status (n=3, excluded from study). In the asylum seeker group, the median age was 18.6 months (range 10 months-5.3 years) with the majority less than 2 years (n=11). All burns occurred in the domestic setting. Scalds accounted for 13 cases, one contact burn occurred from a hot grill. The median total body surface area burned was 5.7% (range 1.5-26%). The National Census of 2002 recorded a population of 3,917,203. With less than 12,000 asylum seekers in the country, they comprise only approximately 0.3% of the population yet they account for 11.4% of the burn patients admitted to our unit, p<0.0001. Children of asylum seekers are over-represented in our series of paediatric admissions for burns and are more likely than Irish children to sustain a burn at a younger age and in the domestic setting. This may indicate an increased risk of injury and warrants further investigation.     

Staged Bilateral Total Knee Arthroplasty : Does History Dictate the Future?

A retrospective cohort study of 668 staged bilateral TKA patients was conducted to determine first-side versus second-side subjective and objective outcomes. Improvement in patient perceived function, measured by one-year Oxford Score (OKS) was defined by a minimal clinically important difference of > 5 points in OKS. Results indicate that patients who had a minimal clinically important improvement (MCII) on the first-side have a significantly greater chance of maintaining or improving benefit with second-side TKA (OR 3.2; 95% CI 1.63–6.22; P = 0.000). Of those with no clinical improvement (NCI), 71.4% achieved MCII on the second-side, while 28.6% remained NCI (P = 0.000). Patients who do not initially benefit from first-side TKA should not be denied second-side staged-TKA as they still have a significant chance of achieving an MCII.     

Cementless Total Knee Arthroplasty in Obese Patients : A Prospective Matched Study With Follow-Up of 5–10 Years

A prospective matched cohort study was performed to compare outcomes of cementless total knee arthroplasties between 171 knees in obese patients (BMI ≥ 30) and 171 non-obese patients (BMI < 30). Mean follow-up was 7 years. There were no significant differences in overall functional outcomes or components alignment. In the obese group, there were 14 perioperative complications, 9 revisions, and 5 other patients were considered clinical failures, whereas in the non-obese group there were 3, 5, and 7, respectively. There were no significant differences between obese class I–II and class III (morbid) subgroups. The obese and non-obese groups had similar implant survivorship at 7 years. Although TKA outcome in obese was satisfactory, these patients should be informed of the perioperative risks, and advised to lose weight prior to surgery.     

Workers' Compensation Patients After Total Joint Arthroplasty : Do They Return to Work?

Clinicians identify patients receiving Workers' Compensation (WC) as unlikely to fully benefit from total joint arthroplasty (TJA), with possibly decreased ability to return to work. We completed follow-up for 164 patients undergoing 177 arthroplasties while receiving WC between 2000 and 2009. Inquiry was made regarding work status, nature of work, and return to work time frame. Patients undergoing primary versus revision TJA returned to work 70.2% versus 43.9%, respectively (p = 0.002). The mean time frame for return to work following primary TJA was 16.4 weeks. Manual laborers versus sedentary workers returned to work 67.1% versus 84.8%, respectively (p = 0.05). As this group is limited by the strenuous nature of their employment, clinicians should be aware that receiving WC may modestly impact return to work following arthroplasty.     

Where to start?: Attempting to meet the psychological needs of burned patients

The National Burn Care Review Committee [National Burn Care Review Committee. National Burns Care Review. Standards and Strategy for Burn Care; 2001] recommend routine psychosocial screening for all burned in-patients, as well as access to different levels of psychological input. This paper aims to report on: (1) a system which integrates routine clinical practice, psychological screening and a system of data collection to identify level of need; (2) an audit of the range of levels of psychological input required to meet this need. All consecutive admissions (n=72) to a regional burns unit were screened within a week of admission using the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale (IES) and a screening tool developed in the unit. Clinical input was provided as required and recorded. Thirty-five percent reported a previous mental health problem. Forty percent fell into 'borderline' or 'caseness' on the HADS. Fifteen percent met a level of clinical 'caseness' on both the intrusions and avoidance subscales of the IES. Sixty-three percent required some level of psychological input during their in-patient stay. Given the high level of need identified and the range of levels of psychological intervention identified, a system of routine screening and a tiered model of psychological care is proposed to best utilise psychological resources.     

A clinical forensic scientist in the burns unit: Necessity or not?: A prospective clinical study

Child abuse by burning is a common means of assault that may be difficult to prove. Even though well trained in burns management physicians on the burn team may not be sufficiently qualified to clarify the medicolegal aspects of the incident. In Turkey, physicians have a responsibility to notify the law offices of injury to children caused by any non-accidental mechanism including neglect. The consequences of false positive and/or false negative reports to the legal offices may be damaging for the care-takers and/or the children. In our study, 239 consecutively hospitalized children with burns were studied prospectively. A clinical forensic scientist and a physician of the burns team interpreted incidents separately so that neither had an idea about the other's diagnoses until the end of the study. There were found to be some differences in the interpretation of the incidents by the clinical forensic scientist and the burns team physician. These differences were described as discordant diagnoses. The physician accepted 99 (41.4%) of the incidents as an accident while only 66 (27.6%) of the victims were labelled as accidents by the forensic scientist. A multivariate analysis identified low socioeconomic status, aged between 3 and 6 years, and a family size of more than six as independent variables significantly associated with discordant diagnoses (p = 0.0388, 0.0001, 0.0203, respectively). As a conclusion, we suggest that to minimize the likelihood of a legally inaccurate diagnosis, a clinical forensic scientist seems to be necessary in the emergency department.     

A Comparison of Acetate vs Digital Templating for Preoperative Planning of Total Hip Arthroplasty : Is Digital Templating Accurate and Safe?

The purposes of this study were to compare the accuracy of acetate and digital templating for primary total hip arthroplasty (THA) and to determine if digital templating is safe. Preoperative planning was performed on 50 consecutive preoperative radiographs during 2005. Templating results were compared with the actual hip implants used. Interrater reliability of acetate templating and accuracy of acetate and digital templating were recorded. Digital measurement overestimated acetabular size (P < .001) and underestimated the femoral size (P = .03). The absolute errors were larger for digital compared with acetate templating; however, mean absolute errors did not differ significantly (acetabulum, P = .090; femur, P = .114). Acetate and digital templating can accurately predict the size of THA implants. Digital templating was determined to be acceptably safe for preoperative planning of primary THA operations.