Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri‐operative period 1, 2. The advice presented is based on previously published advice and clinical studies.

Lavage solution temperature influences depth of chondrocyte death and surface contouring during thermal chondroplasty with temperature-controlled monopolar radiofrequency energy

BACKGROUND

Although radiofrequency energy can smooth and contour cartilage surface, it has deleterious effects on chondrocyte viability.

HYPOTHESIS

Monopolar thermal chondroplasty in a 37 degrees C lavage solution, as compared with a 22 degrees lavage solution, will reduce chondrocyte death and result in greater smoothing of the articular cartilage surface.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixteen chondromalacic samples from patients undergoing total knee arthroplasty were divided into two groups: 22 degrees C and 37 degrees C lavage solution. Each sample was divided into two equal parts and half of each group was treated for 10 seconds and the other half for 15 seconds.

RESULTS

Confocal laser microscopy demonstrated that the depth of chondrocyte death in the 37 degrees C lavage solution group was significantly less (range, 200 to 340 microm) than that in the 22 degrees C solution group for both 10- and 15-second treatment times. Scanning electron microscopy demonstrated that the cartilage surface in the 37 degrees C lavage solution group was smoother than that in the 22 degrees C solution group for the 10-second treatment time. Energy delivery power in the 37 degrees C lavage solution group was significantly lower than in the 22 degrees C solution group for both treatment times.

CONCLUSIONS

Thermal chondroplasty with 37 degrees C lavage solution resulted in less depth of chondrocyte death and produced smoother surfaces than with 22 degrees C solution for 10 seconds of treatment.

CLINICAL RELEVANCE

Less chondrocyte death would permit increased use of thermal chondroplasty.

Fracture of the femoral prosthesis in total hip replacement according to Charnley

An analysis of 14 fractures of the stem of the early design of low friction arthroplasty showed a predominance of heavy, bilaterally operated males. The total incidence was 0.67 per cent. The fractures occurred between 14 months and 5 years postoperatively. Every fracture was preceded by radiological signs of loosening caused by varus positioning of the femoral head prosthesis and defective cement support medially at the femoral calcar.

Can particulate air sampling predict microbial load in operating theatres for arthroplasty?

Several studies have proposed that the microbiological quality of the air in operating theatres be indirectly evaluated by means of particle counting, a technique derived from industrial clean-room technology standards, using airborne particle concentration as an index of microbial contamination. However, the relationship between particle counting and microbiological sampling has rarely been evaluated and demonstrated in operating theatres. The aim of the present study was to determine whether particle counting could predict microbiological contamination of the air in an operating theatre during 95 surgical arthroplasty procedures. This investigation was carried out over a period of three months in 2010 in an orthopedic operating theatre devoted exclusively to prosthetic surgery. During each procedure, the bacterial contamination of the air was determined by means of active sampling; at the same time, airborne particulate contamination was assessed throughout the entire procedure. On considering the total number of surgical operations, the mean value of the total bacterial load in the center of the operating theatre proved to be 35 CFU/m(3); the mean particle count was 4,194,569 no./m(3) for particles of diameter ≥0.5 µm and 13,519 no./m(3) for particles of diameter ≥5 µm. No significant differences emerged between the median values of the airborne microbial load recorded during the two types of procedure monitored. Particulates with a diameter of ≥0.5 µm were detected in statistically higher concentrations (p<0.001) during knee-replacement procedures. By contrast, particulates with a diameter of ≥5 µm displayed a statistically higher concentration during hip-replacement procedures (p<0.05). The results did not reveal any statistically significant correlation between microbial loads and particle counts for either of the particle diameters considered (≥0.5 µm and ≥5 µm). Consequently, microbiological monitoring remains the most suitable method of evaluating the quality of air in operating theatres.

Design of the PROCON trial: a prospective, randomized multi-center study comparing cervical anterior discectomy without fusion, with fusion or with arthroplasty

BACKGROUND

PROCON was designed to assess the clinical outcome, development of adjacent disc disease and costs of cervical anterior discectomy without fusion, with fusion using a stand alone cage and implantation of a Bryan's disc prosthesis. Description of rationale and design of PROCON trial and discussion of its strengths and limitations.

METHODS/DESIGN

Since proof justifying the use of implants or arthroplasty after cervical anterior discectomy is lacking, PROCON was designed. PROCON is a multicenter, randomized controlled trial comparing cervical anterior discectomy without fusion, with fusion with a stand alone cage or with implantation of a disc. The study population will be enrolled from patients with a single level cervical disc disease without myelopathic signs. Each treatment arm will need 90 patients. The patients will be followed for a minimum of five years, with visits scheduled at 6 weeks, 3 months, 12 months, and then yearly. At one year postoperatively, clinical outcome and self reported outcomes will be evaluated. At five years, the development of adjacent disc disease will be investigated.

DISCUSSION

The results of this study will contribute to the discussion whether additional fusion or arthroplasty is needed and cost effective.

Cervical arthroplasty: material properties

Discectomy, decompression, and fusion are traditionally used to manage cervical disc disease accompanied by neural element compression that is refractory to conservative management. Concerns regarding stress at levels adjacent to fusion and possible adjacent-level degeneration as well as a desire to maintain a more normal biomechanical environment have led to investigation of cervical disc replacement as an alternative to fusion procedures. Cervical disc prostheses currently under investigation are constructed of predominantly metal-on-polyethylene or metal-on-metal bearing surfaces, and use roughened titanium surfaces and osteoconductive coatings to facilitate fixation. The unique anatomy and biomechanics of the cervical spine must be considered when extrapolating from the experience of appendicular arthroplasty and lumbar disc replacement.

A Comparison of Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion in Patients with Two-Level Cervical Degenerative Disc Disease: 5-Year Follow-Up Results

OBJECTIVE

To present a long-term clinical and radiographic comparison between the Prestige LP cervical disc replacement and the Zero-P spacer cervical disc fusion in the treatment of patients with symptomatic 2-level cervical degenerative disease.

METHODS

In total, 36 patients in the anterior cervical discectomy and fusion (ACDF) group and 24 patients in the cervical disc arthroplasty (CDA) group were analyzed before surgery and at 1 week and 3, 6, 12, 24, and 60 months after surgery. Clinical assessments included the Japanese Orthopaedic Association score, visual analog scale, and Neck Disability Index scores. Radiographic assessments included cervical lordosis, range of motion (ROM) of the total cervical spine, functional spinal unit (FSU), and superior and inferior adjacent segments. Complications including heterotopic ossification and adjacent-segment degeneration (ASD) at 5-year follow-up were collected as well.

RESULTS

Mean follow-up period was 65.6 months. Both the ACDF and CDA groups showed significant clinical improvements in terms of Japanese Orthopaedic Association score, visual analog scale, and Neck Disability Index (P < 0.05), but there was no significant difference between groups at the last follow-up period. A significant increase of cervical lordosis was observed in the CDA group after surgery whereas a significant difference was not observed between groups. ROM of the total cervical spine and FSU were maintained during the follow-up, and a significant decrease was observed in the ACDF group after surgery (P < 0.05). The ROM of the superior adjacent segment did not show any difference whereas the ROM of the inferior adjacent segment in the ACDF group presented a significant increase at 6 months and 1 year after surgery and a significant decrease at the last follow-up period. A total of 8 (33.3%) patients in the CDA group had an occurrence of heterotopic ossification. ASD was observed in 2 (8.3%) patients who underwent CDA surgery and 8 (22.2%) patients who underwent ACDF surgery.

CONCLUSIONS

The use of the Prestige-LP and ZERO-P Spacer implantations is safe and effective. At 5 years after surgery, CDA with Prestige-LP is superior in terms of ROM of the total cervical spine, FSU, and inferior adjacent segment. It also has a relatively low occurrence rate of ASD. This procedure may be a suitable choice for the treatment of contiguous 2-level CDDD.

Involving physicians in clinical pathways: an example for perioperative knee arthroplasty

BACKGROUND

At Stanford University Hospital, attempts to improve the case management program led to the development of clinical paths, a multidisciplinary case management tool. Successful design and implementation of clinical paths depend on physician leadership. However, since physicians are trained to function independently and to treat each clinical problem as unique, they tend to resist attempts to have them follow clinical paths. Strategies to get physicians who perform the same clinical procedure to agree with each other on a sequence of common interventions had to be developed. Clinical paths define the expected processes of care and therefore allow for the introduction of continuous quality improvement (CQI) into the clinical arena. A structure had to be developed for the effective use of pathways in a CQI framework, and physicians had to be encouraged to function as CQI leaders.

EXAMPLE

Description of the design of a perioperative knee arthroplasty pathway demonstrates the steps needed for successful physician involvement in pathway design and its integration into clinical CQI.

CONCLUSIONS

With sensitive facilitation, physicians can become productive leaders of the design of clinical paths, and when they learn the benefits of improved efficiency, outcomes, and costs their involvement becomes self-sustaining. A quality improvement group led by physicians to develop the pathway after implementation can mark the beginning of clinical CQI implementation.

[Role of scapho-trapezo-trapezoidal arthrodesis in the treatment of Kienbock disease. 11 cases]

11 patients with Decoulx stage III Kienböck's disease with rotatory subluxation of the scaphoid were treated with scapho-trapezo-trapezoid arthrodesis. The associated procedures were lunate implant resection arthroplasty in 6 cases, lunate resection in 3 cases, shortening of the radius in 1 case. The average follow-up was 40 months (12 to 84 months). There was no complication of the arthrodesis. Relief of pain is satisfactory in 7 of the 11 patients. The average grip strength is 66% of that observed on the affected side. The range of movement was decreased especially for radial deviation. There was a positive correlation between, the exact scaphoid reduction, a wrist without preoperative degenerative arthritis and the good clinical results. No differences were observed in the results between the associated lunate procedures. STT fusion seems to be a useful procedure in the treatment of stage III Kienböck's disease with carpal malalignment as it removes compressive stress from the diseased lunate and treats, the accompanying rotatory subluxation of the scaphoid.

A comparison of the Freeman-Swanson (ICLH) and Walldius prostheses in total knee replacement

Seventy-five Freeman-Swanson (ICLH) Mark I total knee replacements, all performed in one orthopaedic unit between 1972 and 1975, were independently reviewed. The fifty-eight surviving patients, with sixty-eight arthroplasties, have been interviewed and examined and the clinical records of the deceased patients inspected. Sixty arthroplasties (80 per cent) were successful and fifteen failed (20 per cent). There were no disasters. Twenty (33.8 per cent) of the successful arthroplasties were excellent. It is expected that modification of the prosthesis and improved instrumentation will increase this percentage of excellent results and reduce the failure rate.

Single-tunnel anatomic double-bundle anterior cruciate ligament reconstruction has the same effectiveness as double femoral, double tibial tunnel: A prospective randomized study

PURPOSE

To investigate whether single femoral, single tibial tunnel anatomic double-bundle anterior cruciate ligament (ACL) reconstruction is equal to or superior to double femoral, double tibial tunnel ACL double-bundle anatomic reconstruction in terms of restoring the stability and functions of the knee joint.

METHODS

A prospective clinical study was performed to compare 30 cases of single-tunnel ACL double-bundle anatomic reconstruction to 28 cases of double-tunnel ACL double-bundle anatomic reconstruction, with average follow-up of 36 months. All graft tendons were hamstring tendon autografts. Tunnel placements in all the cases were made anatomically. Clinical results were collected after reconstruction. Graft appearance, meniscus status and cartilage state under arthroscopy were compared and analyzed.

RESULTS

Tunnel placements were in the anatomic positions in both groups. On the lateral pivot-shift test performed at 36 months postoperatively, there was no significant difference between groups. Clinical results such as International Knee Documentation Committee score, Tegner activity scale, and range of motion showed no significant differences between the groups. The mean thickness of anteromedial graft was reduced by 10.3% and that of the posterolateral graft was reduced by 11.1% from the original graft thickness evaluated by magnetic resonance imaging. No new meniscal tears were found either group; however, cartilage damage occurred in the double-tunnel group at 39.3%, and this rate was significantly higher than that in the single-tunnel group (10.0%).

CONCLUSION

Single femoral, single tibial tunnel anatomic double-bundle ACL reconstruction has the same effectiveness as the double femoral, double tibial tunnel in restoring the knee's stability and functions.

Establishing a Successful Outpatient Joint Arthroplasty Program

Many surgical procedures are performed in outpatient settings, and outpatient joint replacements are one of the emerging trends in orthopedics. Rising consumer demand for value-driven health care, new technology, and pain management advancements, and more physicians training in minimally invasive surgical techniques during their residency have driven this change. When a facility is considering the establishment of an outpatient joint arthroplasty program, leaders must take into consideration the outcomes data from the facility's current joint arthroplasty program. Additional factors in establishing a successful outpatient program include careful patient selection, preoperative patient education, the presence of a case manager, and specialized protocols and techniques.

[Operative technique of arthroplastic resection of the three proximal bones]

Proximal row carpectomy is a controversial operative technique for difficult wrist problems. Based upon resection of bones, it represents in fact a reconstructive technique of a new joint. The majors steps of the technique are described in detail.