Introduction

Prosthetic joint infection (PJI) and aseptic loosening in total hip arthroplasty (THA) can present with pain and osteolysis. The International Consensus Group on Periprosthetic Joint Infection (ICGPJI) have provided criteria for the diagnosis of PJI. The aim of our study was to analyse the utility of F18-Fluoro-deoxy-glucose (FDG) Positron Emission Tomography (PET) CT scan in the pre-operative diagnosis of septic loosening in THA based on the current ICGPJI definition of prosthetic joint infection.

Materials and method

130 painful unilateral cemented THAs were included in this prospective study. Pre- operative evaluation with inflammatory markers and aspiration were performed. F18-FDG PET scan was performed. Diagnostic utility tests were performed based on the ICGPJI criteria for PJI and three samples positive on culture alone.

Results

130 patients had FDG PET. The mean ESR, CRP and WCC were 47.83 mm/hr, 25.21 mg/l and 11.05×109/l respectively. The sensitivity, specificity, accuracy negative predictive value and false positive rate of FDG PET compared with ICGPJI criteria were 94.87%, 38.46 %, 56.38%, 94.59 % and 60.21% respectively. The false positive rate of FDG PET compared with culture alone was 77.4%. The mean follow-up was 5.17±1.12 years.

Conclusion

FDG PET has a definitive role in the pre-operative evaluation of suspected PJI. To the best of our knowledge this the first study to evaluate its utility based on ICGPJI criteria and compare it microbiology results alone. However, it has a high false positive rate. Therefore, we suggest that 18-F-FDG PET is useful in confirming the absence of infection, but if positive, may not be confirmatory of PJI.

Background:

According to 2018 National Hip Fracture Database (NHFD) annual report only 31.4% of intracapsular neck of femur fracture (NOF) patients eligible for Total Hip Replacement (THR) received this operation.The aim was to Identify compliance rates of THR for NOF and rationale for management in our unit.

Methods:

During the period January 2014 to December 2018, patients identified by NHFD as eligible for THR for displaced NOF were included. Day of injury and surgery was identified in excel, type and reasons for performing particular procedure were identified from the notes. Demographics, pre-operative Abbreviated Mental Test Score (AMTS), time to surgery, delay and length of stay were analysed using chi-squared test.

Results:

Only 138 out of 315 patients eligible for THR underwent THR. The rest (177) had alternative management (mainly hip hemiarthroplasty or fixation). Patients aged 60-79 years were more likely to receive THR than >79 years (p<0.05). THR patients had 0.4 higher AMTS and length of stay was shorter (9.5 vs 12.6) (p<0.05). There were significantly more females and left sided fractures but neither was relevant to type of surgery performed. Waiting time for THR and non-THR surgery was similar (1.4 vs. 1.1 day) (p>0.05) with no “weekend effect”. Consultant level documented reasons for not performing THR was present in 93% of notes. Reasons included patient choice, significant medical, mental health and mobility issues. When rationale for surgical decision-making is taken into consideration, our unit had 93% compliance for performing THR for displaced NOF in >60 year olds compared to published national rate of 44%.

Conclusion:

Data requested by NHFD is not sufficient to decide whether patients meet criteria for THR, potentially skewing the result on THR for NOF performance. A column in NHFD database allowing units to record reasons for not performing THR would give more credibility to published data.

Background:

Management of complex, comminuted distal femoral fractures present a challenge to orthopaedic surgeons. High rate of complications are associated with surgical management of such injuries especially in elderly patients. This study aims to review the outcome of surgical fixation of these complex injuries at our trauma unit, to identify correctable surgical factors associated with rate of union.

Methods:

Patients undergoing open reduction, internal fixation of distal femoral fractures at our Institute from 2008 to 2018 were included in the study. A retrospective analysis of patient factors, surgical parameters, complications and union rate was performed.

Results:

79 patients were included in the analysis with mean age of 73 years (range, 33-101 years). There were 11 male and 68 female patients. The mean time to surgery was 3 days (0-14 days). There were 58 native femur fractures and 21 periprosthetic fractures. All patients had fixation with locking plates with MIPO technique. Those patients (49/79) who had fixation performed with longer plates (>10 holes) and ‘flexible construct’ achieved 100% union rate. However, there were 3(10%) non-unions in patients where fracture fixation was performed with ‘stiff construct’ (p=0.05). These three patients eventually healed with revision surgery using longer plates and flexible construct.

Conclusion:

Longer plate with ‘end to end’ fixation of femur in comminuted distal femur fractures employing flexible construct are related to improved outcomes. Stiff construct and short plates may lead to non-union in such complex injuries. Longer plates and ‘flexible constructs’ are recommended to fix comminuted distal femoral fractures to increase the union rate.

Background:

The aim of this study was to evaluate randomised trials for significant findings in the orthopaedic literature based on the main elective procedures undertaken across different subspecialties.

Methods:

We evaluated the following procedures: anterior cervical discectomy and fusion (ACDF), subacromial decompression (SAD), carpal tunnel decompression (CTD), total hip replacement (THR), anterior cruciate ligament reconstruction (ACLR), total knee replacement (TKR) and hallux valgus correction (HVC). Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 1), Ovid MEDLINE (1946 to 12 January 2018) and Embase (1980 to 12 January 2018). Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings.

Results:

We included 1078 RCTs across seven most commonly performed elective procedures. Of those, only 16% (172/1078) reported significant findings [ACDF 26/77 (33.8%); SAD 2/22 (9%); CTD 11/72 (15.3%); THR 52/281 (18.5%); ACLR 21/239 (8.8%); TKR 55/357 (15.4%); HVC 5/30 (16.7%)]. The number of RCTs per year of publication has increased dramatically particularly since early 2000s—with over 100 RCTs of those seven procedures published in 2017 alone.

Conclusions:

This is the first study to undertake a comprehensive review of orthopaedic RCTs in elective practice. The number of RCTs in orthopaedic research is steadily increasing. However, only 16% of trials reports significant differences between interventions. For trials comparing different surgical techniques, this evidence provides treating surgeons with the flexibility to utilise available resources and infrastructure to deliver patients care without compromising clinical outcomes

Introduction

A paradigm shift has recently been observed in limb reconstruction surgery, with a move away from external fixators where it is possible to achieve the same results using internal fixation. Accuracy with internal fixation is critical as there is no opportunity to adjust correction postoperatively.

Materials and Methods

A review of consecutive external fixator assisted deformity corrections was performed using electronic records and radiographs to analyse preoperative and postoperative lower limb alignment. All patients under 18 treated with this technique were included.

Results

33 segments in 21 patients were corrected between 2012 and 2018 with an average of 3.4 years follow up (1-6.4). 19 of these were tibial and 14 femoral corrections. Multiplanar deformity was corrected in 9 segments. Varus (25 segments) was more common than valgus deformity. The cause of deformity varied with the most frequent causes being trauma, meningococcal infection, longitudinal deficiency, hypophosphataemic rickets and Blount’s disease. Median age at surgery was 15.5 (3-18). A statistically significant improvement was seen between median preoperative and postoperative mechanical axis deviation (preoperative 36mm, postoperative 14mm, p=0.00001). Correction of LDFA and MPTA improved femoral deformity from a median magnitude of 15 to 2 degrees (p=0.001). Tibial deformity improved from a median magnitude of 16 to 2 degrees (p=0.0001). Osteotomies united radiologically at a median of 3.1 months (2-9.7) with one proximal femoral non-union requiring revision surgery. Two deformities corrected at age 7 recurred and required further surgery. There was one common peroneal nerve palsy despite prophylactic neurolysis, two superficial infections and three patients required metalwork removal.

Conclusions

External fixator assisted deformity correction is accurate and allows inexpensive trauma implants to be used to maintain the correction. Preoperative planning, simulation of deformity correction and intraoperative external fixator control allows patients with multilevel, multiplanar deformities to be treated with internal fixation.