Cost induced by hip fractures

Hip fracture is the most common fracture in the elderly population. Treating hip fractures is a major burden on the Irish Health system. There is no recent Republic of Ireland study detailing hospital costs for such injuries. A comprehensive analysis of 143 patients admitted with a hip fracture was performed to determine current medical expenditure incurred during acute hospitalization for hip fractures during 2005 in a major university hospital. Costs associated with surgery (implant & theatre costs), laboratory, radiology, physiotherapy and ward were calculated on individual basis. All the hip fractures were above 60 years of age (mean 82 years); average stay in the hospital was 11 days. The mean total hospital expenditure per patient was Euro 9236.01 of which ward costs contributed 55.33%, operative costs 39.82% and investigations 4.83%. The result clearly show that hip fractures have a major economic impact arising from the inpatient treatment, most of which relate to length of hospital stay.

Outcome following deep wound contamination in cemented arthroplasty

Infection remains a devastating complication of joint replacement surgery causing a significant burden to both patient and surgeon. However, despite exhaustive prophylactic measures, intraoperative contamination still occurs during cemented arthroplasty with current infection rates of 1-2%. A study was undertaken to determine the incidence of perioperative contamination in cemented arthroplasty patients, to identify contaminating organisms, to identify contaminated regions within the operative wound, to identify factors associated with increased contamination, and finally to assess the medium-term clinical outcome in patients with confirmed intraoperative wound contamination. Eighty consecutive patients undergoing hip and knee cemented arthroplasty were prospectively enrolled over a 6-month period. All scrubbed personnel wore total body exhaust isolation suits and procedures were carried out in ultra-clean air theatres. Of 441 samples, contamination was identified at 21 sites (4.8%) representing a cohort of 18 patients (22.5%). Longer duration of surgery predisposed to higher contamination rates while lower contamination rates were significantly related to fewer gowned personnel within the ultra-clean system, and fewer total personnel in theatre during the procedure. None of the patients developed clinical evidence of deep prosthetic infection at follow-up. We noted a high incidence of intraoperative contamination despite standard prophylaxis. However, this was not reflected by a similar rate of postoperative infection. This may be due to a small bacterial inoculum in each case or may be due to the therapeutic effect of perioperative intravenous antibiotic prophylaxis.

Revision of the Sheehan total knee arthroplasty

The use of the Sheehan knee prosthesis extended from 1971 to 2002. It incorporated a semi-constrained hinge with intra-medullary stems cemented into the femur and tibia. While some authors have reported excellent short-term results, others have reported revision rates of up to 31% at 5--10 years. The aim of this study was to review the senior author's experience in revising these arthroplasties. We review 54 Sheehan total knee replacements and discuss the difficulties encountered during first and subsequent revisions and the often-complex reconstruction techniques used to overcome these.

Occupational noise levels in orthopaedic surgery

Prolonged exposure to potentially damaging noise levels in the workplace has been the subject of much recent litigation. The occupational risk of noise induced hearing loss among orthopaedic surgeons is unknown. Continuous readings of air-powered instruments routinely used in orthopaedic surgery were made in a regional trauma unit at standard distance from the noise source. All instruments generated noise levels greater than the threshold for routine monitoring of hearing loss under health and safety legislation.

Femoral cementing techniques in total hip replacement

Clinical studies have shown that second-generation femoral cementing techniques at total hip replacement result in a superior fixation of the femoral stem. In an effort to determine what benefits further developments in cementing techniques would provide, we compared the morphology of the cement mantles produced by traditional finger-packing and gun-insertion techniques. The porosity of the cement mantles was quantified using computerised image analysis. The finger-packing technique caused large air inclusions that resulted in large pores in the substance of the cement mantle, whereas the cement-gun technique did not result in any individual pore with an equivalent diameter greater than 3 mm. The mean porosity of cement mantles prepared using the finger-insertion technique was 8.3%, whereas the mean porosity in gun-prepared mantles was 1.7%. The use of a cement gun significantly reduced the porosity of femoral cement mantles (P = 0.02). Reduction of defects in the substance of the cement mantle may account for the increased survival of femoral prostheses inserted when second-generation techniques were used. Further reduction of the porosity of the cement mantle could not be expected to produce as dramatic a clinical improvement in prosthesis fixation.

Interprosthetic fracture of the femoral shaft

Experience in the management of a complication of ipsilateral hip and knee arthroplasty is described. The cases of four female patients who sustained a femoral shaft fracture after ipsilateral hip and knee arthroplasty are reported. All fractures were treated operatively, and in all cases internal fixation devices failed. This complication of multiple joint arthroplasty presents a difficult management problem. Rigid fixation has a high failure rate for this type of fracture. Surface knee arthroplasty provides a better opportunity for internal fixation than a knee arthroplasty with a stemmed femoral component.

16- to 25-year follow-up study of cemented arthroplasty of the hip in patients aged 50 years or younger

The clinical outcome of the cemented Charnley hip arthroplasty at follow-up periods of 16-25 years was evaluated retrospectively in patients aged 50 years or younger. One hundred thirty-two of a total of 167 hip arthroplasties were studied. The overall probability of survival of the implant at 20 years was 75% Survival of those with rheumatoid disease was 80% compared with 64% for those with osteoarthritis. Female sex was associated with a better prognosis. Accelerated wear was associated with decreased survival of the prosthesis. Varus orientation of the femoral component significantly influenced failure (P < .01). Radiographic loosening of the acetabular component was well tolerated, but loosening of the femoral component was significantly associated with pain (P = .01).

Risk of pelvic injury from femoral neck guidewires

Many of the devices used in the internal fixation of femoral neck fractures are cannulated and require the initial placement of one or more guidewires for accurate positioning. These wires are occasionally advanced inadvertently through the hip joint and the acetabulum. Pelvic visceral damage may follow. To assess this risk, we inserted three guidewires to a depth of 16 cm into each femoral neck of ten cadavers and explored the pelvis during autopsy. Thirty-two of the 60 guidewires had penetrated a pelvic organ. The literature on intrapelvic injuries associated with hip surgery is reviewed, and suggestions are offered on the avoidance of pelvic penetration during hip fracture fixation.

Risks of radiation exposure to orthopaedic surgeons

The risks of occupational radiation exposure for orthopaedic surgeons has not been well documented. The use of fluoroscopy in orthopaedics has reduced morbidity and by reducing operative time and by reducing the invasiveness of procedures. Increasingly procedures requiring the use of fluoroscopy are being developed. In a prospective study we have monitored cumulative radiation exposure over a 6-month period. The exposure levels are well below the maximum dose limits for ionizing radiation as recommended by European Economic Communities EURATOM directives. Experimentally using a phantom patient it was shown that the exposure to ionizing radiation during the insertion of a dynamic hip screw was minimal. Despite the low level of exposure care should be exercised when using fluoroscopy.

Bacterial arthritis in the neurosurgical patient: report on four cases

Bacterial arthritis that occurred in four patients during neurosurgical convalescence is reported. Three patients had a cerebral aneurysm clipped after a subarachnoid hemorrhage, and one had herpes simplex encephalitis with a possible temporal lobe hemorrhage. All four patients had been treated with steroids. A total of six joints were infected, two patients with an infection in one joint each, and two with a metachronous infection in two joints. The interval between the onset of local symptoms and the definitive diagnosis ranged from 0 to 44 days. A delay in diagnosis severely compromises joint function, and all four of these patients were left with an associated significant musculoskeletal disability. Bacterial arthritis is well recognized in the immunocompromised patient, but, to our knowledge, has not been described in this particular clinical setting. A patient with a sustained pyrexia of unknown origin in the neurosurgical convalescent period should be suspected of having an occult musculoskeletal infection. An isotope bone scan to facilitate early diagnosis is recommended, and this, combined with specific aggressive therapy, should preserve joint function.

Contrasting levels of in vitro cytokine production by rheumatoid synovial tissues demonstrating different patterns of mononuclear cell infiltration

Synovial membrane samples obtained at knee arthroplasty from 22 patients with rheumatoid arthritis (RA) were characterized histologically. Two groups were identified. Tissue samples from 15 patients demonstrated multiple focal lymphoid aggregates of mononuclear cells (group A). Samples from the remaining seven patients demonstrated diffuse mononuclear cell infiltration (group B). Samples of each synovial membrane (0.25 g) were cultured for cytokine production. The highest levels of IL-1 beta and IL-6 were produced by group A tissues: 19.1 +/- 19.6 ng/ml IL-1 beta (mean +/- s.d.) and 264.4 +/- 301.9 ng/ml IL-6, versus 3.8 +/- 6.6 ng/ml and 54.7 +/- 42.6 ng/ml respectively. Small quantities of IL-2 and IL-4 were measured in both groups: the levels of IL-2 in group A cultures were highest (P = 0.04). Moreover, using MoAbs, the most intense cytokine staining in the tissues was detected in group A. Similar total numbers of each cell subpopulation and similar quantities of immunoglobulin and rheumatoid factor synthesis were measured in both groups. It is suggested that the presence of multiple focal lymphoid aggregates associated with higher levels of cytokine production observed in group A represent a greater degree of immunological activation, and may represent a subgroup of patients with a greater potential for articular destruction.

The Guildford elbow

The Guildford elbow is a new unconstrained elbow arthroplasty. From 1985 to 1991, this arthroplasty was used in 24 patients with rheumatoid arthritis. The patients were reviewed after an average of 28 months (4-59 months). Good to excellent results were obtained in 95% regarding pain relief and functional improvement. Complications were few, with only one case of clinical loosening and three of radiological loosening. Ulnar nerve hypo-aesthesia was common but did not jeopardize the final result in any patient.

Fracture dislocation of the fifth metacarpal resulting in compression of the deep branch of the ulnar nerve

A volar fracture dislocation of the base of the fifth metacarpal resulted in compression of the deep branch of the ulnar nerve. Operative correction of the deformity resulted in full recovery.

Mortality and morbidity associated with hip fractures

In this study 147 patients with hip fractures were reviewed and reassessed to establish their mortality and morbidity. The early mortality was 10.8% and this rose to 27% at three months. The major factors which determined mortality and morbidity were the age of the patient, male sex, and the degree of social dependence of the patient both before and after the fracture. The site of the fracture or the type of anaesthetic used did not significantly affect the outcome. The shortage of Nursing Home and long-term care facilities resulted in prolonged hospital stay for many patients.

Radiological assessment of atlanto-axial injuries

Injury to the cervical spine is a potentially lethal condition, and the accurate detection of such injury is essential. Plain cervical radiography remains the first line of investigation, despite well documented difficulty with interpretation. There have been many studies demonstrating unreliability of plain cervical radiography in detecting atlanto-axial injuries. We report a group of patients in which false-positive interpretation of such injuries occurred.

Analysis of the histologic variation of synovitis in rheumatoid arthritis

One hundred forty-five synovial biopsy specimens were obtained from 30 procedures performed on the knee joints of 29 patients with rheumatoid arthritis. All patients had clinically active rheumatoid arthritis and none had received slow-acting disease-modifying drugs or intraarticular corticosteroids. Scores were assigned to each biopsy specimen for each of 6 histologic features to quantify variation within each joint. In the majority of knee joint biopsies, there was considerable clustering of scores for all histologic features. Thus, on a scale of 0-10, 82% of the scores for synoviocyte hyperplasia were within 1 point of the median score for a given joint. Similarly, between 69% and 85% of the scores for the remaining features (fibrosis, vessel proliferation, perivascular infiltrates, focal aggregates, and diffuse infiltrates of lymphocytes) were within 1 point of the median values. Multiple biopsies were obtained at arthroscopy in 8 patients. Tissue was selected from areas of apparent maximal and minimal involvement, to enhance the likelihood of regional histologic variation. Of the scores for synoviocyte hyperplasia, 91% were within 1 point of the median values for a given joint, and of the scores for the remaining 5 features, 72-94% fell within 1 point of the median values. In addition, highly significant statistical correlations of the intensity of synovial lining layer hyperplasia, vessel proliferation, mononuclear cell infiltration, fibrosis, and clinical measurements of synovitis were observed.

Strut fracture and other events after valve replacement with the 60 degree convexoconcave Björk-Shiley prosthesis

A total of 688 patients received 808 Björk-Shiley prostheses during a 5 year span. Cumulative duration of follow-up totaled 1175.4 patient-years (1368 valve-years). Linearized rates in percent per patient-year for valve-related events (95% confidence limits) were: strut fracture, 0.5 (0.00 to 1.03); infective endocarditis, 0.94 (0.39 to 1.49); thromboembolism, 2.2 (1.37 to 3.052); valve impingement, 0.3 (0.00 to 0.77); and anticoagulant-related hemorrhage, 3.1 (2.15 to 4.14). No valve thrombosis occurred. Actuarial patient survival, including in-hospital mortality, was: aortic valve replacement, 79.8 +/- 3.4%; mitral valve replacement, 71.7 +/- 4.9%; double valve replacement, 59.8 +/- 7.5%. Incremental risk factors for death were age over 65 (p = .001), preoperative infective endocarditis (p = .04), and associated procedures (p = .0002). Although this prosthesis carries a low risk of infective endocarditis and thromboembolism, concern has been raised regarding its structural integrity.

Supracondylar fractures of the humerus in adults

Thirty consecutive supracondylar fractures of the humerus, treated by open reduction and internal fixation over a 4-year period from 1980 to 1984, are reviewed. We feel that anatomical reduction with rigid fixation allowing immediate postoperative movement gives the least morbidity and best results.

Fractures of the femoral shaft treated by plating

Eighty-six fractures of the femoral shaft were treated by open reduction and plating. Seventy-seven fractures (90 per cent) were reviewed 12-72 months (average 38 months) after operation. An excellent or good result was achieved in 70 fractures (91 per cent). There was no case of deep infection. The most common complication was a fatigue fracture of the plate, which occurred in five cases. In patients over the age of 60 years, loosening of the implant was troublesome. Primary bone grafting is essential if rigid internal fixation is not obtained. Plating is an excellent method of treating fractures of the femoral shaft in patients under the age of 60 years, provided that the surgeon is technically competent and experienced in this method of treatment.

The diagnosis of knee injuries in casualty--a prospective study

A prospective study of all knee injuries seen at a Casualty Department was organized. A clinical diagnosis was made in each case, based on standardized criteria, and the subsequent progress followed. Meniscal tears tended to be over-diagnosed clinically. Many injuries thus classified settled in three to four weeks without further sequelae. Conversely, complete ligament tears were under-diagnosed and in particular these tended to be missed in the presence of a haemarthrosis. Examination under anaesthesia is recommended if there is any doubt concerning ligamentous stability and all unexplained haemarthrosis should have early examination under anaesthesia and arthroscopy. Among those injuries initially regarded as less serious e.g. traumatic synovitis, no serious pathology subsequently emerged.