A. J. M. D. Andrade

Hemiarthroplasty using cemented or uncemented stems of proven design

National Institute of Clinical Excellence guidelines state that cemented stems with an Orthopaedic Data Evaluation Panel (ODEP) rating of > 3B should be used for hemiarthroplasty when treating an intracapsular fracture of the femoral neck. These recommendations are based on studies in which most, if not all stems, did not hold such a rating. This case-control study compared the outcome of hemiarthroplasty using a cemented (Exeter) or uncemented (Corail) femoral stem. These are the two prostheses most commonly used in hip arthroplasty in the UK. Data were obtained from two centres; most patients had undergone hemiarthroplasty using a cemented Exeter stem (n = 292/412). Patients were matched for all factors that have been shown to influence mortality after an intracapsular fracture of the neck of the femur. Outcome measures included: complications, re-operations and mortality rates at two, seven, 30 and 365 days post-operatively. Comparable outcomes for the two stems were seen. There were more intra-operative complications in the uncemented group (13% vs 0%), but the cemented group had a greater mortality in the early post-operative period (n = 6). There was no overall difference in the rate of re-operation (5%) or death (365 days: 26%) between the two groups at any time post-operatively. This study therefore supports the use of both cemented and uncemented stems of proven design, with an ODEP rating of 10A, in patients with an intracapsular fracture of the neck of the femur.

Streptococcus gallolyticus prosthetic joint infection associated with undiagnosed colonic malignancy

AbstractStreptococcus gallolyticus is a group D streptococcus which was previously classified as part of the S. bovis/S. equinus complex. It is a rare pathogen in prosthetic joint infection but has been demonstrated to have a strong association with colorectal carcinoma. In this case, a patient with no symptomatology suggestive of colorectal carcinoma presented with a S. gallolyticus prosthetic joint infection. Awareness of the association prompted investigation and subsequent diagnosis of colorectal carcinoma which was successfully treated prior to two-stage revision knee replacement. Level of evidence V.

Diagnosis and management of femoroacetabular impingement.

Femoroacetabular impingement (FAI) is a pathological hip condition characterised by abnormal contact between the acetabulum and femoral head–neck junction.1 This can occur within the normal physiological range of motion as a result of osseous abnormalities described as either cam or pincer deformities. Cam deformities describe an abnormal anterosuperior femoral head–neck junction, whereas pincer deformities describe abnormalities in the shape or orientation of the acetabulum (Figure 1). Some patients have both deformities, designated mixed pathology.2 Impingement can also occur in a morphologically normal hip as a result of extreme range of motion activities, such as in ballet dancers or gymnasts. Figure 1 Illustrative lateral view of a hip showing a) cam deformity with additional bone at the anterior femoral headneck junction (shown in red) b) normal hip c) pincer deformity with additional bone at the anterior acetabular rim (shown in red). The deformities in a) and c) cause the femoral neck to impact against the labrum and acetabular rim on flexion and internal rotation. Repeated abutment of the femoral neck against the acetabular rim can result in injury to the labrum and adjacent cartilage.3 Over time these focal lesions may progress to more extensive degenerative disease. There is increasing evidence implicating FAI in the development of osteoarthritis (OA).1,4 In a large population study, cam …

Corail uncemented hemiarthroplasty with a Cathcart head for intracapsular hip fractures

The National Institute for Health and Clinical Excellence (NICE) guidelines from 2011 recommend the use of cemented hemi-arthroplasty for appropriate patients with an intracapsular hip fracture. In our institution all patients who were admitted with an intracapsular hip fracture and were suitable for a hemi-arthroplasty between April 2010 and July 2012 received an uncemented prosthesis according to our established departmental routine practice. A retrospective analysis of outcome was performed to establish whether the continued use of an uncemented stem was justified. Patient, surgical and outcome data were collected on the National Hip Fracture database. A total of 306 patients received a Cathcart modular head on a Corail uncemented stem as a hemi-arthroplasty. The mean age of the patients was 83.3 years (SD 7.56; 46.6 to 94) and 216 (70.6%) were women. The mortality rate at 30 days was 5.8%. A total of 46.5% of patients returned to their own home by 30 days, which increased to 73.2% by 120 days. The implant used as a hemi-arthroplasty for intracapsular hip fracture provided satisfactory results, with a good rate of return to pre-injury place of residence and an acceptable mortality rate. Surgery should be performed by those who are familiar with the design of the stem and understand what is required for successful implantation.

Invasive group A streptococcal infection: AN UPDATE ON THE EPIDEMIOLOGY AND ORTHOPAEDIC MANAGEMENT

Invasive group A streptococcus (iGAS) is the most common cause of monomicrobial necrotising fasciitis. Necrotising infections of the extremities may present directly to orthopaedic surgeons or by reference from another admitting specialty. Recent epidemiological data from the Health Protection Agency suggest an increasing incidence of iGAS infection in England. Almost 40% of those affected had no predisposing illnesses or risk factors, and the proportion of children presenting with infections has risen. These observations have prompted the Chief Medical Officer for the Central Alerting System in England to write to general practitioners and hospitals, highlighting the need for clinical vigilance, early diagnosis and rapid initiation of treatment in suspected cases. The purpose of this annotation is to summarise the recent epidemiological trends, describe the presenting features and outline the current investigations and treatment of this rare but life-threatening condition.

Gemella haemolysans spondylodiscitis

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis. We describe the clinical features, investigations and treatment options.

A Traffic Light Grading System of Hip Dysplasia to Predict the Success of Arthroscopic Hip Surgery

Background: The role of hip arthroscopic surgery in dysplasia is controversial. Purpose: To determine the 7-year joint preservation rate after hip arthroscopic surgery in hip dysplasia and identify anatomic and intraoperative features that predict the success of hip preservation with arthroscopic surgery, allowing the formulation of an evidence-based classification system. Study Design: Case-control study; Level of evidence, 3. Methods: Between 2008 and 2013, 111 hips with dysplastic features (acetabular index [AI] >10° and/or lateral center-edge angle [LCEA] <25°) that underwent arthroscopic surgery were identified. Clinical, radiological, and operative findings and the type of procedure performed were reviewed. Radiographic evaluations of the operated hip (AI, LCEA, extrusion index) were performed. Outcome measures included whether the hip was preserved (ie, did not require arthroplasty) at follow-up and the preoperative and postoperative Non-Arthritic Hip Score (NAHS) and Hip disability and Osteoarthritis Outcome Score (HOOS). The AI and LCEA were calculated, factored by a measure of articular wear (AIf and LCEAf, respectively), according to the University College Hospital, London (UCL) grading system as follows: AIf = AI × (number of UCL wear zones + 1), and LCEAf = LCEA / (number of UCL wear zones + 1). A contour plot of the resulting probability value of failure for every combination of AIf and LCEAf allowed for the determination of the zones with the lowest and highest incidences of failure to preserve the hip. Results: The mean AI and LCEA were 9.8° and 18.0°, respectively. At a mean follow-up of 4.5 years (range, 0.4-8.3 years), 33 hips had failed, requiring hip arthroplasty. The 7-year joint survival rate was 68%. The mean improvements in the NAHS and HOOS were 11 (P = .001) and 22.8 (P < .001) points, respectively. The zone with the greatest chance of joint preservation (odds ratio, 10; P < .001) was the green zone, with an AIf of 0° to 15° and an LCEAf of 15° to 25°; in contrast, the zone with the greatest chance of failure (odds ratio, 10; P < .001) was the red zone, with an AIf of 20° to 100° and an LCEAf of 0° to 10°. Conclusion: Overall, the 7-year hip survival rate in hip dysplasia appears inferior compared with that reported in femoroacetabular impingement (78%). Hip arthroscopic surgery is associated with an excellent chance of hip preservation in mild dysplasia (green zone: AI = 0°-15°, LCEA = 15°-25°) and no articular wear. The authors advise that the greatest caution should be used when considering arthroscopic options in cases of severe dysplasia (red zone: AI >20° and/or LCEA <10°).

Does lumbar arthrodesis compromise outcome of total hip arthroplasty

Introduction: This matched cohort study aims to determine whether the presence of a spinal arthrodesis (SA) compromises outcome of total hip arthroplasty (THA) and whether the outcome is better if THA is performed before- (THA-1st) or after- SA (THA-2nd). Methods: This is a single centre, multi-surgeon, review of prospective data. Thirty-seven patients (47 hips) that had SA and 1° THA(s), formed the cases (26 THA-1st; 21 THA-2nd). Most cases had 1-level SA (n = 24). Controls were patients without SA that had THA, over the same period matched for age, gender and prosthesis type. Outcome measures included complication-, revision- rates, Oxford-Hip- and Harris-Hip-Scores (OHS/HHS) (Δ: difference between pre- and post-operative scores). This is a single-centre, multi-surgeon, review of prospective data. Results: At a mean follow-up of 6 years, more complications were seen in cases of THA and SA compared with controls without SA (7 vs. 2) (p = 0.03). Consequently, more cases were revised (n = 4) compared with controls (n = 0) (p = 0.02). There were no differences in functional outcome between cases and controls (p = 0.1–0.6). No differences in complications- (4/26 vs. 3/21; p = 1.00) or revision- rates (2/26 vs. 2/21; p = 1.00) were seen between THA-1st and THA-2nd Groups. The THA-1st Group had higher pre- and post-operative OHS/HHS, compared to the THA-2nd Group. However, no significant difference in ΔOHS (24 vs. 17) and ΔHHS (39 vs. 26) were seen between the THA-1st and THA-2nd Groups (p = 0.1). Conclusions: Patients with THA and SA, had increased rates of revision; but no differences in patient-reported outcome measures (PROMs) were detected. Addressing the hip pathology first may be associated with improved functional outcome.