Gordon Bannister

Prevalence and functional impact of patient-perceived leg length discrepancy after hip replacement

The aim of this postal survey was to determine the prevalence and impact of patient-perceived leg length discrepancy (LLD) at 5–8xa0years after primary total hip replacement (THR). A postal audit survey was undertaken of all consecutive patients who had a primary unilateral THR at one elective orthopaedic centre between April 1993 and April 1996. The questionnaire included the Oxford hip score (OHS) and questions about LLD. Questionnaires were received from 1,114 patients. In total, 329 THR patients (30%) reported an LLD, although radiographic analysis revealed that only 36% of these patients had anatomical LLD. Patients with a perceived LLD had a significantly poorer OHS (p < 0.001) and reported more limping than those patients without a perceived LLD. This study found that a third of patients perceived an LLD after THR and that perceived LLD was associated with a significantly poorer midterm functional outcome.RésuméLe but de cette étude est de déterminer l’impact et la perception des patients secondaires à une inégalité de longueur (LLD) entre 5 et 8 ans de recul après une prothèse totale de hanche. Matériel et méthode: Nous avons réalisé une enquête postale concernant une série consécutive de patients ayant bénéficié d’une prothèse totale de hanche unilatérale réalisée dans notre centre entre avril 1993 et avril 1996. Ce questionnaire incluait par ailleurs le score d’Oxford (OHS) et des questions concernant cette inégalité de longueur. Résultats: ces questionnaires ont été reçus par 1 114 patients. Au total 329 (30%) rapportaient une inégalité de longueur mais, l’analyse radiographique montrait que seulement 36% de ces 30% avaient une véritable inégalité de longueur anatomique. Les patients qui se plaignent d’une inégalité de longueur après prothèse totale de hanche ont un score d’OHS significativement plus bas que les autres (p < 0.001) et une boiterie de durée plus longue si on la compare à ceux qui ne se déclarent pas porteur d’une inégalité de longueur. En conclusion, cette étude montre qu’un tiers des patients se plaignent d’une inégalité de longueur après prothèse totale de hanche et que cette inégalité de longueur est associée à une résultat fonctionnel significativement plus bas que celui des patients sans inégalité de longueur.

Maximum temperatures of 89°C recorded during the mechanical preparation of 35 femoral heads for resurfacing

Background and purpose We noticed that our instruments were often too hot to touch after preparing the femoral head for resurfacing, and questioned whether the heat generated could exceed temperatures known to cause osteonecrosis. Patients and methods Using an infra-red thermal imaging camera, we measured real-time femoral head temperatures during femoral head reaming in 35 patients undergoing resurfacing hip arthroplasty. 7 patients received an ASR, 8 received a Cormet, and 20 received a Birmingham resurfacing arthroplasty. Results The maximum temperature recorded was 89°C. The temperature exceeded 47°C in 28 patients and 70°C in 11. The mean duration of most stages of head preparation was less than 1 min. The mean time exceeded 1 min only on peripheral head reaming of the ASR system. At temperatures lower than 47°C, only 2 femoral heads were exposed long enough to cause osteonecrosis. The highest mean maximum temperatures recorded were 54°C when the proximal femoral head was resected with an oscillating saw and 47°C during peripheral reaming with the crown drill. The modified new Birmingham resurfacing proximal femoral head reamer substantially reduced the maximum temperatures generated. Lavage reduced temperatures to a mean of 18°C. Interpretation 11 patients were subjected to temperatures sufficient to cause osteonecrosis secondary to thermal insult, regardless of the duration of reaming. In 2 cases only, the length of reaming was long enough to induce damage at lower temperatures. Lavage and sharp instruments should reduce the risk of thermal insult during hip resurfacing.

The functional outcome of the fractured clavicle

BackgroundThe severity of symptoms, rate and completeness of recovery after closed treatment of the fractured clavicle has not been fully explored.MethodsThe severity and duration of pain, analgesic requirements, ability to perform daily activities, return to work, driving and sport along with appearance of the shoulder were recorded in 56 patients between 1 and 2xa0years after fracture. Radiographs were assessed by Robinson’s classification [8].ResultsTwenty-two out of 56 patients described functional restriction 1–2xa0years after injury. The majority of patients ceased to experience pain (34/56) and returned to work (19/46) within 3xa0months. Thirty-eight out of 56 patients noted cosmetic deformity, the severity of which was associated with worse functional outcome (pxa0=xa00.002). The degree of fracture displacement was associated with cosmetic deformity (pxa0=xa00.02) and functional outcome (pxa0=xa00.015).ConclusionThe majority of patients perceive a cosmetic deformity and 22/56 impaired function after clavicular fracture.

The thermal effects of lavage on 57 ox femoral heads prepared for hip resurfacing arthroplasty

Background and purpose Previously, we have documented surface temperatures recorded by thermography great enough to cause osteonecrosis of the femoral head during hip resurfacing. We now performed an in vitro investigation with 3 questions: (1) whether water irrigation reduced bone surface temperature, (2) whether external bone temperatures were similar to core temperatures, and (3) whether blunting of the reamer affected temperature generation. Methods Using an ox-bone model, 57 femoral heads were peripherally reamed. The surface temperatures of bone were measured using a thermal camera and internal bone temperatures were measured using 2 theromocouples. We measured the effects of cooling with water at room temperature and with ice-cooled water. Progressive blunting of reamers was assessed over the 57 experiments. Results Mean and maximum temperatures generated during peripheral reaming were greater when no irrigation was used. Ice-cold saline protected femoral heads from thermal damage. External bone temperatures were much greater than internal temperatures, which were not sufficiently elevated to cause osteonecrosis regardless of lavage. Blunting of the reamer was not found to have a statistically significant effect in this study. Interpretation Cooling with ice-cooled water is recommended. Internal bone temperatures are not elevated despite the high surface temperatures reached during femoral head resurfacing.

Post-traumatic immunosuppression is reversed by anti-coagulated salvaged blood transfusion: deductions from studying immune status after knee arthroplasty: Reversal of post-traumatic immunosuppression

Major trauma increases vulnerability to systemic infections due to poorly defined immunosuppressive mechanisms. It confers no evolutionary advantage. Our objective was to develop better biomarkers of post‐traumatic immunosuppression (PTI) and to extend our observation that PTI was reversed by anti‐coagulated salvaged blood transfusion, in the knowledge that others have shown that non‐anti‐coagulated (fibrinolysed) salvaged blood was immunosuppressive.

Post-traumatic immunosuppression is reversed by anti-coagulated salvaged blood transfusion

Major trauma increases vulnerability to systemic infections due to poorly defined immunosuppressive mechanisms. It confers no evolutionary advantage. Our objective was to develop better biomarkers of post‐traumatic immunosuppression (PTI) and to extend our observation that PTI was reversed by anti‐coagulated salvaged blood transfusion, in the knowledge that others have shown that non‐anti‐coagulated (fibrinolysed) salvaged blood was immunosuppressive.

Skin closure after total hip replacement a randomised controlled trial of skin adhesive versus surgical staples

We undertook a randomised controlled trial to compare the outcomes of skin adhesive and staples for skin closure in total hip replacement. The primary outcome was the cosmetic appearance of the scar at three months using a surgeon-rated visual analogue scale. In all, 90 patients were randomised to skin closure using either skin adhesive (n = 45) or staples (n = 45). Data on demographics, surgical details, infection and oozing were collected during the in-patient stay. Further data on complications, patient satisfaction and evaluation of cosmesis were collected at three-month follow-up, and a photograph of the scar was taken. An orthopaedic and a plastic surgeon independently evaluated the cosmetic appearance of the scars from the photographs. No significant difference was found between groups in the cosmetic appearance of scars at three months (p = 0.172), the occurrence of complications (p = 0.3), or patient satisfaction (p = 0.42). Staples were quicker and easier to use than skin adhesive and also less expensive. Skin adhesive and surgical staples are both effective skin closure methods in total hip replacement.