Does the modified Harris hip score reflect patient satisfaction after hip arthroscopy?

BACKGROUND

No published studies have explored the relationship between commonly reported clinical outcomes and patient satisfaction after hip arthroscopy.

PURPOSE

To compare the modified Harris Hip Score (mHHS) with patient satisfaction in a prospective study over a 2-year period.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We reviewed our institutional database for prospectively collected mHHS and patient satisfaction data from 697 patients. Patients were evaluated preoperatively and at 1 and 2 years after surgery.

RESULTS

The mHHS correlated with patient satisfaction at 1 year (P < .001, Pearson R = 0.451) and at 2 years (P < .001, Pearson R = .454). Considering scores from excellent to good as positive results and from fair to poor as negative results, sensitivity was 73% at 1 year and 77% at 2 years. Respectively, the specificity was 64% and 73%, positive predictive value 86% and 91%, negative predictive value 45% and 46%, and accuracy 71% and 76%. At 1- and 2-year follow-up, a respective 55% and 54% of patients with fair to poor mHHS were satisfied with the outcome of hip arthroscopy. In contrast, for those patients with an excellent to good mHHS at 1 and 2 years after surgery, 14% and 9%, respectively, were dissatisfied with their outcome.

CONCLUSION

Our results show a correlation between patient satisfaction and the mHHS but also demonstrate a limitation of the mHHS as an outcome measure in the prediction of patient satisfaction. Further investigation is required to assess factors beyond current standard orthopaedic clinical outcome measures that may influence patient satisfaction after hip arthroscopy.

Revision hip arthroscopic surgery: outcome at three years

PURPOSE

This study describes the medium-term results of revision hip arthroscopy.

METHODS

Patients with persistent hip pain and a positive impingement sign were considered for revision surgery after the exclusion of other causes of groin pain. Seventy-four consecutive patients were prospectively assessed using the modified Harris hip score for a period of 3 years after surgery. Of the 74 patients, 11 had inadequate follow-up data; thus, a total of 63 patients were qualified for the study. The mean age at index surgery was 37 years, comprising 27 males and 36 females.

RESULTS

Revision surgery was performed at a mean of 3 years from index surgery. Chondral lesion associated with labral re-injury was the most common finding at revision arthroscopy. In contrast to other authors, however, only 31 % of our patients underwent revision for persistent femoroacetabular impingement. The mean pre-operative mHHS for all 63 patients was 54 (SD 14.5). The mean post-operative mHHS was 53 (SD 14.9) at 6 weeks, 62 (SD 17.5) at 6 months, 63 (SD 16.5) at 1 year, 64 (SD 16.5) at 2 years and 59 (SD 16.5) at 3 years (p = n.s., 0.02, 0.045, 0.039 and n.s., respectively).

CONCLUSIONS

Revision arthroscopy results in improvement in outcome in the first 3 years after revision surgery with a success rate of 63.4 % at 1 year, falling to 55.6 % by 3 years.

Magnetic resonance arthrography for femoroacetabular impingement surgery: is it reliable?

BACKGROUND

Magnetic resonance arthrography (MRA) is commonly used to demonstrate injury to the labrum and hyaline cartilage in patients with femoroacetabular impingement (FAI). The purpose of this study was to assess the diagnostic correlation between MRA and findings at arthroscopic and open surgery.

MATERIALS AND METHODS

MRA reports of 41 hips with symptomatic FAI were reviewed and compared with subsequent intraoperative findings (n = 21 surgical dislocations and n = 20 therapeutic hip arthroscopies). Each case was assessed for the presence of a cam deformity, a cartilage lesion of the femoral head, an os acetabuli, an injury to the labrum and injury to the acetabular cartilage. Results were collected prospectively in a cross-table and analysed retrospectively for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

The sensitivity, specificity, PPV and NPV in the presence of reported cam-type deformity or an os acetabuli were 100%. In the presence of cartilage lesions of the femoral head, the values were 46, 81, 55 and 73%, respectively. For labral tears, the values were 91, 86, 97 and 67%. In the presence of acetabular cartilage injuries, the values were 69, 88, 78 and 81%, respectively.

CONCLUSIONS

MRA appears to be an efficacious imaging modality in the evaluation of labral tears, cam-type impingement lesions and os acetabuli of the hip. MRA is less efficacious in the diagnosis of cartilage abnormalities in the hip, both femoral and acetabular. Researchers should focus on further improvements in imaging techniques in order to give reliable preoperative information to the surgeon.

The significance of low density microfilaraemia in the transmission of Wuchereria bancrofti by Culex (Culex) quinquefasciatus Say in Sri Lanka

Laboratory-bred Culex quinquefasciatus were fed on carriers with low and moderate densities of microfilariae (mf) of Wuchereria bancrofti. In the first series of experiments, mosquitoes were dissected 12 d after feeding. The percentage of infected mosquitoes and the numbers of larvae per infected mosquito were directly proportional to the mf density at the time of feeding. There was an overall high infection rate and a wide distribution of larvae per individual mosquito at all levels, except for the 4 lowest counts. Of the 4 carriers with counts of 5 mf/ml and less, 3 were capable of infecting Cx quinquefasciatus, giving infection rates of 1.0%, 7.4% and 12.0% respectively. In the second series, some mosquitoes were dissected immediately after feeding and the remainder 12 d later. There was a good correlation between the number of mf ingested and the number of infective larvae per mosquito. The high infection rates in Cx quinquefasciatus when fed on low-density microfilaraemia carriers, and the varying number of larvae in individual mosquitoes, suggest that low-density carriers could be a source of infection. Field studies were also carried out in 3 different area with mf rates of 7.24%, 0.72% and 0.16%, respectively. In the 2 areas with low mf rates, infection rates in mosquitoes were 1.32% and 1.08% respectively. Cx quinquefasciatus fed on a carrier with a residual microfilaraemia of 19 mf/ml following treatment with diethylcarbamazine had an infection rate of 13.8%. These studies suggest that the examination of recently fed house-resting populations of Cx quinquefasciatus could be a sensitive method for measuring the prevalence of mf in the human population.

Hip Arthroscopy in the Presence of Acetabular Dysplasia

PURPOSE

Hip arthroscopy is a well established therapeutic intervention for an increasing number of painful hip conditions. Developmental dysplasia of the hip (DDH) is commonly associated with intra-articular hip pathology. However, some surgeons perceive patients with hip dysplasia as poor candidates for hip arthroscopy. Our aim was to describe early outcomes of arthroscopic treatment for patients with DDH, who also had femoroacetabular impingement (FAI) treated when necessary, and to compare these outcomes against a control group of patients without DDH.

METHODS

Prospective case-control study of 68 consecutive hip arthroscopy patients assessed with a modified Harris Hip Score (mHHS) preoperatively and at six weeks, six months, and one year after surgery. Presence of DDH was determined using a standard anteroposterior (AP) pelvic radiograph to measure the centre-edge angle (CEA) of Wiberg, with a CEA < 20º used as threshold for diagnosis of DDH.

RESULTS

12 patients (eight female and four male) with acetabular dysplasia and mean CEA of 15.4º (9º to 19º). The control, nondysplastic group comprised 54 patients (23 females and 31 males) with a mean CEA of 33.1º (22º to 45º). All patients in the dysplastic group had a labral tear and 11 (91.7%) had associated femoral cam impingement lesion addressed at arthroscopy. Our study demonstrates a significant (p=0.02) improvement in outcome in the dysplastic group at one year using the mHHS.

CONCLUSION

Hip arthroscopy in the presence of DDH is effective in relieving pain for at least one year after surgery although does not address underlying acetabular abnormality.

Medium term results of the collum femoris preserving hydroxyapatite coated total hip replacement

We describe the survival of 75 collum femoris preserving (CFP) hydroxyapatite (HA) coated uncemented total hip replacement stems with a mean follow-up of 43 months (range 12-60). Patients were assessed using the Harris Hip Score. Radiographs were evaluated using Gruen zones and DeLee and Charnley zones. The criteria for failure were revision or impending revision. The mean Harris Hip Score was 50 preoperatively improving to 94 at final review, with 3 patients lost to follow-up. One cup was revised for aseptic loosening, whilst none of the stems required revision. Survivorship was 97% and 100% at 3 years for the cup and stem respectively. Our findings suggest that the medium term results of the CFP stem are excellent.

Does ligament balancing technique affect kinematics in rotating platform, PCL retaining knee arthroplasties? A prospective randomized study

The goal of this prospective, randomized, blinded trial was to determine if ligament balancing techniques for rotating platform TKA affect postoperative knee kinematics. Sixteen patients with unilateral rotating platform TKA consented to participate in this institutional review board approved study. Eight patients were randomly selected to receive ligament balancing with an instrumented joint spreader device and eight patients received ligament balancing using fixed thickness spacer blocks. A single plane shape matching technique was used for kinematic analysis of static deep knee flexion and dynamic stair activities. There were no differences in knee kinematics between groups during static deep flexion activities. The spreader group demonstrated kinematics more similar to the normal knee during the ascending phase of the dynamic stair activity. Knee kinematics in static knee flexion were unaffected by ligament balancing technique, while knees balanced with the spreader demonstrated a medial pivot motion pattern during stair ascent. This medial pivot motion pattern may improve long-term results by more closely replicating normal knee kinematics.

Myositis Ossificans Traumatica of the Thenar Region

Myositis ossificans of the hand is extremely rare. We report an unusual case of myositis ossificans of the thenar muscles and discuss the diagnostic pitfalls whereby this condition can be mistaken for malignancy or infection.

Medial patellofemoral ligament reconstruction: a technique with a "v"-shaped patellar tunnel

Patellofemoral dislocation is a common problem affecting the young and active population. The medial patellofemoral ligament (MPFL) is torn when the patella dislocates as it acts as a checkrein to lateral displacement. This leads to patellar instability, and MPFL reconstruction is required if the dislocation recurs after a trial of rehabilitation. We describe a "V"-shaped patellar tunnel technique to reconstruct the MPFL using an autologous gracilis graft. This modification of the patellar tunnel does not breach the lateral cortex of the patella, and it allows a broader attachment of the tendon graft to the patella, which mimics the normal anatomic attachment of the MPFL to the patella.

Combined Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Transfer Results at a Follow-Up of 2 years

There is limited data on the effectiveness of combined medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle transfer (TTT) in patients with patella instability. The aim of our study was to analyze the functional outcome in patients treated with MPFL reconstruction and TTT. Between July 2008 and April 2013, 18 patients (21 knees) underwent combined MPFL reconstruction and TTT; 15 patients (16 knees) with a mean age of 24 years (16-41) had a mean follow-up of 30 months (26-55). There was significant improvement in outcome scores in 12 out of 15 patients. KOOS score improved from 68.25 (44-93.9) to 77.05 (48.8-96.4) and KUJALA score improved from 63.3 (41-88) to 78.06 (45-99). Nine patients achieved at least a preinstability level of activity. Out of these nine patients, four had activity level better than the preinstability level. The remaining six patients had a lower activity level than preinstability level (2-lack of confidence and 4-lifestyle modification). Fourteen patients were satisfied and happy to recommend this procedure. There were three postoperative complications, with two cases of stiffness and one case of nonunion of the tibial tuberosity. Thus, the restoration of tibial tubercle to trochlear groove distance, patella height, and MPFL reconstruction yields good results in carefully selected patients.

Peri-articular diseases of the hip: emerging frontiers in arthroscopic and endoscopic treatments

The precise diagnosis of both intra and extra-capsular disease of the hip is now possible because of commonly available advanced diagnostic imaging techniques. An increasing number of reports in the orthopedic literature describe new endoscopic and arthroscopic techniques to address peri-articular pathology of the hip. The purpose of this paper is to review current techniques in the management of extra-articular hip conditions.

Use of a simple suture to stabilize the chevron osteotomy: a prospective study

A clinical and radiographic review was undertaken in 27 patients (30 feet) who underwent a chevron osteotomy stabilized with a double loop of polydioxanone suture. The mean patient age at the time of surgery was 40 years (range, 16 to 66 years). At 6 weeks postoperatively, all patients showed clinical and radiographic union at the osteotomy site. In 1 foot, the initial correction was lost with radiographic evidence of an angulated distal fragment with no medial translation. There were no cases of wound infection, sinus formation, or avascular necrosis of the metatarsal head. No patients required further surgery. This method of stabilizing a chevron osteotomy is technically straight forward, with a predictable outcome, and provides a valid low cost alternative to screw, bioabsorbable implant, or Kirschner wire.

Physical Examination of the Carpal Bones by Orthopaedic and Accident and Emergency Surgeons

Our aim was to test knowledge of carpal bone surface anatomy among orthopaedic and accident and emergency surgeons. A survey of 58 surgeons was conducted. Each was asked to palpate seven points on five commonly injured carpal bones. Eight surgeons declined to participate. Five of the remaining 50 correctly palpated all surface markings. Six failed to accurately palpate even a single point. The scaphoid waist and trapezial ridge were accurately palpated by 47 surgeons. The median score for all participants was 3 correctly identified points. The majority of orthopaedic and accident and emergency surgeons do not perform an accurate physical examination of the carpal bones. The ancient art of history taking, precise physical examination and elucidation of a confident diagnosis is at risk of being replaced with tentative diagnoses and imaging techniques that are expensive and time consuming. We believe that basic anatomical teaching is inadequate.

Fat pad entrapment at the hip: a new diagnosis

PURPOSE

To establish if a positive impingement sign in femoroacetabular impingement (FAI) may result from entrapment of the fat pad located at the anterior head-neck junction of the upper femur. This fat pad is routinely removed before any cam lesion excision.

METHODS

We report a prospective study of 142 consecutive hip arthroscopies for symptomatic FAI where the aim was to remove the arthroscopically identified area of impingement, not necessarily to create a spherical femoral head. Patients were divided into two groups. Group 1 (n = 92; 34 females, 58 males), where a cam-type bony FAI lesion was identified and excised in addition to the fat pad which overlay it, and Group 2 (n = 50; 29 females, 21 males) where the only identified point of impingement was a prominent fat pad. In this situation the fat pad was excised in isolation and the underlying bone preserved. Patients were assessed preoperatively, at six weeks, six months, one year and two years with a modified Harris hip score (mHHS).

RESULTS

Both groups were comparable preoperatively for mean age, mean alpha angle and mean anterior offset ratio. Both groups improved significantly after surgery at all time points. However, Group 1 (fat pad and bone resection) demonstrated 16.0% improvement in mHHS by two years while for Group 2 (fat pad resection only) the improvement was 18.9% (p = 0.628).

CONCLUSIONS

The fat pad found at the anterior head/neck junction of the hip joint can be a source of pain and we propose fat pad entrapment as a new, previously undescribed diagnosis. Our findings also suggest that a large number of cam lesions are being excised unnecessarily and that further efforts should be made to understand the role of the fat pad as a source of groin discomfort.

LEVEL OF EVIDENCE

Level IV, case series.

Safer mobile fluoroscopy in the trauma theatre: a survey of orthopaedic registrars and theatre staff

The Ionising Radiation (Protection of Persons Undergoing Medical Examination or Treatment) Regulations 1988 (POPUMET) made it compulsory from June 1990 for all staff directing medical exposures to ionising radiation to receive formal tuition at a core knowledge course. This course described the hazards of ionising radiation and the safe use of x-ray equipment. It instructed on the nature of ionising radiation and its interaction with tissues, principles and means of dose reduction to patient and operator, the importance of using the patient’s existing radiological information and statutory responsibilities. The POPUMET course was discontinued following the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R). IR(ME)R training for healthcare professionals is available as a half-day theoretical course suitable for those designated as ‘referrer’ by their employers. Other locally run ionising radiation protection courses are tailored to the varied requirements of a spectrum of healthcare professionals.

Patients' Perception of Bone and Tissue Excision, and the Size and Weight of Prostheses at Total Knee Arthroplasty

The aim of this study is to ascertain patients' perception of the amount of bone and tissue excision and size and weight of their implanted prostheses at total knee arthroplasty (TKA). To our knowledge, no prior study in the English orthopaedic literature has analyzed these parameters against patient perception of TKA. In a prospective study of eight consecutive TKA (six primary and two single-stage revision TKA procedures) by a single surgeon, patients estimated the weight of their implanted knee. We assessed actual weights of their implants and bone cement. Patients estimated the size of their prostheses by sketching the tibial and femoral bone cuts upon a printout of an anteroposterior and lateral radiographs of their preoperative knee. We utilized an articulated plastic model knee for patient reference. Our study shows almost half a kilogram of weight is added postoperatively to the surgical site as a result of tissue excision, explanted material, and implanted prosthesis and cement. All patients overestimated the weight of their implanted prostheses and extent of bone excision. Thus, even 'well-informed' patients overestimate their bone resection and weight of implanted prosthesis at TKA. We postulate such misconceptions among TKA patients are common, and may impact negatively upon patient perception of TKA, their postoperative recovery and outcome.

Safety of intraarticular corticosteroid injection preceding hip and knee arthroplasty: a systematic review and meta-analysis amid resolving COVID-19 arthroplasty restrictions

Intraarticular corticosteroid injection (ICSI) is a widely practiced management for hip and knee osteoarthritis. Imposed delays to arthroplasty during coronavirus disease 2019 pandemic have led us to postulate that many patients have opted for recent ICSI. We compared the odds of prosthetic joint infection (PJI) in patients who were or were not administered ICSI within 12 months prior to hip or knee arthroplasty. A systematic search of PubMed, Embase, The Cochrane Library and Web of Science was performed in February 2021, with studies assessing the effect of ICS on PJI rates identified. All studies, which included patients that received ICSI in the 12 months prior to primary hip and knee arthroplasty, were included. In total 12 studies were included: four studies with 209 353 hips and eight studies with 438 440 knees. ICSI administered in the 12 months prior to hip arthroplasty increased the odds of PJI [odds ratio (OR) = 1.17, P = 0.04]. This was not the case for knees. Subgroup analysis showed significantly higher odds of PJI in both hip [OR = 1.45, P = 0.002] and knee arthroplasty [OR = 2.04; P = 0.04] when ICSI was within the preceding 3 months of surgery. A significantly higher odds of PJI were seen in patients receiving ICSI within the 12 months prior to hip arthroplasty. Subgroup analysis showed increased odds of PJI in both hip and knee arthroplasty, in patients receiving ICSI within 3 months prior to their arthroplasty. We recommend delaying knee arthroplasty for at least 3 months after ICSI and possibly longer for hip arthroplasty.

Synovial fluid calprotectin performs better than synovial fluid polymerase chain reaction and interleukin-6 in the diagnosis of periprosthetic joint infection : a systematic review and meta-analysis

AIMS

The preoperative diagnosis of periprosthetic joint infection (PJI) remains a challenge due to a lack of biomarkers that are both sensitive and specific. We investigated the performance characteristics of polymerase chain reaction (PCR), interleukin-6 (IL6), and calprotectin of synovial fluid in the diagnosis of PJI.

METHODS

We performed systematic search of PubMed, Embase, The Cochrane Library, Web of Science, and Science Direct from the date of inception of each database through to 31 May 2021. Studies which described the diagnostic accuracy of synovial fluid PCR, IL6, and calprotectin using the Musculoskeletal Infection Society criteria as the reference standard were identified.

RESULTS

Overall, 31 studies were identified: 20 described PCR, six described IL6, and five calprotectin. The sensitivity and specificity were 0.78 (95% confidence interval (CI) 0.67 to 0.86) and 0.97 (95% CI 0.94 to 0.99), respectively, for synovial PCR;, 0.86 (95% CI 0.74 to 0.92), and 0.94 (95% CI 0.90 to 0.96), respectively, for synovial IL6; and 0.94 (95% CI 0.82 to 0.98) and 0.93 (95% CI 0.85 to 0.97), respectively, for synovial calprotectin. Likelihood ratio scattergram analyses recommended clinical utility of synovial fluid PCR and IL6 as a confirmatory test only. Synovial calprotectin had utility in the exclusion and confirmation of PJI.

CONCLUSION

Synovial fluid PCR and IL6 had low sensitivity and high specificity in the diagnosis of PJI, and is recommended to be used as confirmatory test. In contrast, synovial fluid calprotectin had both high sensitivity and specificity with utility in both the exclusion and confirmation of PJI. We recommend use of synovial fluid calprotectin studies in the preoperative workup of PJI. Cite this article: Bone Joint J 2022;104-B(3):311-320.