Aetiology of Hip dislocation

Written by the surgeons of the Exeter Hip Team and their colleagues from around the world, this book describes 40 years of innovation and development with cemented hip replacement. Topics covered include the basic science behind successful cemented hip replacement, modern surgical techniques and recent advances. There is also extensive coverage of the revision techniques developed at Exeter and elsewhere, focussing on femoral and acetabular impaction grafting. Each chapter is a self-contained article with an emphasis, where appropriate, on practical techniques and surgical tips, supported by line drawings and intra-operative photographs.

The use of cement in hip arthroplasty

Written by the surgeons of the Exeter Hip Team and their colleagues from around the world, this book describes 40 years of innovation and development with cemented hip replacement. Topics covered include the basic science behind successful cemented hip replacement, modern surgical techniques and recent advances. There is also extensive coverage of the revision techniques developed at Exeter and elsewhere, focussing on femoral and acetabular impaction grafting. Each chapter is a self-contained article with an emphasis, where appropriate, on practical techniques and surgical tips, supported by line drawings and intra-operative photographs.

Femoral impaction grafting in revision total hip arthroplasty

Between 1987 and 1999, 540 revision total hip replacements in 487 patients were performed at our institution with the femoral impaction grafting technique with a cemented femoral stem. All patients were prospectively followed for 2-15years post-operatively with no loss to follow-up. 494 hips remained successfully in situ at an average 6.7years. The ten year survival rate was 98.0% (95% CI 96.2 to 99.8) with aseptic loosening as the endpoint and 84.2% (95% CI 78.5 to 89.9) for re-operation for any reason. Indication for surgery and the use of any kind of reinforcement significantly influenced outcome (p<0.001). This is the largest known series of revision THR with femoral impaction grafting and the results support continued use of this technique.

Wound problems following hip arthroplasty before and after the introduction of a direct thrombin inhibitor for thromboprophylaxis

NICE guidelines have stated that patients undergoing elective hip surgery are at increased risk for venous thromboembolic events (VTE) following surgery and have recommended thromboprophylaxis for 28-35 days1, 2. However the studies looking at the new direct thrombin inhibitors have only looked at major bleeding. We prospectively looked at wound discharge in patients who underwent hip arthroplasty and were given dabigatran postoperatively between March 2010 and April 2010 (n=56). We retrospectively compared these results to a matched group of patients who underwent similar operations six months earlier when all patients were given dalteparin routinely postoperatively until discharge, and discharged home on 150mg aspirin daily for 6 weeks (n=67). Wound discharge after 5 days was significantly higher in the patients taking dabigatran (32% dabigatran n=18, 10% dalteparin n=17, p=0.003) and our rate of delayed discharges due to wound discharge significantly increased from 7% in the dalteparin group (n=5) to 27% for dabigatran (n=15, p=0.004). Patients who received dabigatran were more than five times as likely to return to theatre with a wound complication as those who received dalteparin (7% dabigatran n=4, vs. 1% dalteparin n=1), however, this was not statistically significant (p=0.18). The significantly higher wound discharge and return to theatre rates demonstrated in this study have meant that we have changed our practice to administering dalteparin until the wound is dry and then starting dabigatran. Our study demonstrates the need for further clinical studies regarding wound discharge and dabigatran.

Clinical and radiographic outcomes of acetabular impaction grafting without cage reinforcement for revision hip replacement : a minimum ten-year follow-up study

Impaction bone grafting for reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. We used this technique, in combination with a cemented acetabular component, in the acetabula of 304 hips in 292 patients revised for aseptic loosening between 1995 and 2001. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of 10 years following the index operation. Mean follow-up was 12.4 years (SD 1.5; range 10.0-16.0). Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8%) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared loose radiographically.

Near infrared spectroscopy for rapid determination of Mankin score components : a potential tool for quantitative characterization of articular cartilage at surgery

PURPOSE The purpose of this study was to demonstrate the potential of near infrared (NIR) spectroscopy for characterizing the health and degenerative state of articular cartilage based on the components of the Mankin score. METHODS Three models of osteoarthritic degeneration induced in laboratory rats by anterior cruciate ligament (ACL) transection, meniscectomy (MSX), and intra-articular injection of monoiodoacetate (1 mg) (MIA) were used in this study. Degeneration was induced in the right knee joint; each model group consisted of 12 rats (N = 36). After 8 weeks, the animals were euthanized and knee joints were collected. A custom-made diffuse reflectance NIR probe of 5-mm diameter was placed on the tibial and femoral surfaces, and spectral data were acquired from each specimen in the wave number range of 4,000 to 12,500 cm(-1). After spectral data acquisition, the specimens were fixed and safranin O staining (SOS) was performed to assess disease severity based on the Mankin scoring system. Using multivariate statistical analysis, with spectral preprocessing and wavelength selection technique, the spectral data were then correlated to the structural integrity (SI), cellularity (CEL), and matrix staining (SOS) components of the Mankin score for all the samples tested. RESULTS ACL models showed mild cartilage degeneration, MSX models had moderate degeneration, and MIA models showed severe cartilage degenerative changes both morphologically and histologically. Our results reveal significant linear correlations between the NIR absorption spectra and SI (R(2) = 94.78%), CEL (R(2) = 88.03%), and SOS (R(2) = 96.39%) parameters of all samples in the models. In addition, clustering of the samples according to their level of degeneration, with respect to the Mankin components, was also observed. CONCLUSIONS NIR spectroscopic probing of articular cartilage can potentially provide critical information about the health of articular cartilage matrix in early and advanced stages of osteoarthritis (OA). CLINICAL RELEVANCE This rapid nondestructive method can facilitate clinical appraisal of articular cartilage integrity during arthroscopic surgery.

Clinical results in primary THR

Written by the surgeons of the Exeter Hip Team and their colleagues from around the world, this book describes 40 years of innovation and development with cemented hip replacement. Topics covered include the basic science behind successful cemented hip replacement, modern surgical techniques and recent advances. There is also extensive coverage of the revision techniques developed at Exeter and elsewhere, focussing on femoral and acetabular impaction grafting. Each chapter is a self-contained article with an emphasis, where appropriate, on practical techniques and surgical tips, supported by line drawings and intra-operative photographs.

Clinical results : Acetabular impaction grafting

Written by the surgeons of the Exeter Hip Team and their colleagues from around the world, this book describes 40 years of innovation and development with cemented hip replacement. Topics covered include the basic science behind successful cemented hip replacement, modern surgical techniques and recent advances. There is also extensive coverage of the revision techniques developed at Exeter and elsewhere, focussing on femoral and acetabular impaction grafting. Each chapter is a self-contained article with an emphasis, where appropriate, on practical techniques and surgical tips, supported by line drawings and intra-operative photographs.

An epidemiological study of the relationship between time to surgery and health status for elderly patients with a hip fracture

A hip fracture causes permanent changes to life style for older people. Further, two important mortality indicators found post operatively for this group include, the time until surgery after fracture, and pre-operative health status prior to surgery, yet no research is available investigating relationships between time to surgery and health status. The researchers aimed to establish the health status risks for patients aged over 65 years with a non-pathological hip fracture to guide nursing care interventions. A prospective cohort design was used to investigate relationships between time to surgery and measures on pre-operative health status indicators including, skin integrity risk, vigor, mental state, bowel function and continence. Twenty-nine patients with a mean age in years of 81.93 (SD,9.49), were recruited. The mean number of hours from time 1 assessment to surgery was 52.72 (SD,58.35) and the range was 1 hour to 219 hours. At Time 2, the mean scores of vigor and skin integrity risk were significantly higher, indicating poorer health status. A change in health status occurred but possibly due to the small sample size it was difficult to relate this result to time. However the results informed preoperative care prior to surgery, for this group.

Indications for early hip revision surgery in the UK : A re-analysis of NJR data

This study determined the rate and indication for revision between cemented, uncemented, hybrid and resurfacing groups from NJR (6 th edition) data. Data validity was determined by interrogating for episodes of misclassification. We identified 6,034 (2.7%) misclassified episodes, containing 97 (4.3%) revisions. Kaplan-Meier revision rates at 3 years were 0.9% cemented, 1.9% for uncemented, 1.2% for hybrids and 3.0% for resurfacings (significant difference across all groups, p<0.001, with identical pattern in patients <55 years). Regression analysis indicated both prosthesis group and age significantly influenced failure (p<0.001). Revision for pain, aseptic loosening, and malalignment were highest in uncemented and resurfacing arthroplasty. Revision for dislocation was highest in uncemented hips (significant difference between groups, p<0.001). Feedback to the NJR on data misclassification has been made for future analysis. © 2012 Wichtig Editore.

Apixaban for the prevention of thromboembolism in adults after elective hip or knee replacement surgery, and in symptomatic venous thromboembolism

The anticoagulant effect of apixaban is due to direct inhibition of FXa in the coagulation cascade. The main advantages apixaban has over the current anti-coagulant drugs is that it is active after oral administration, and its coagulation effect does not require monitoring. Apixaban has been compared to enoxaparin in the prevention of venous thromboembolism associated with knee and hip replacement, where it is as efficacious as enoxaparin, but causes less bleeding. However, apixaban is not the only FXa inhibitor that could replace enoxaparin for this indication, as the FXa inhibitor rivaroxaban is as efficacious and safe as enoxaparin in preventing thromboembolism associated with these surgical procedures. Until the results of the AMPLIFY Phase III trial are known, it is too early to consider apixaban as an alternative to enoxaparin in symptomatic thromboembolism. Apixaban should not be used to prevent thromboembolism in medical immobilised subjects or acute coronary syndromes, as it causes excess bleeding in these conditions without benefit.

Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur

Recently the National Patient Safety Agency in the United Kingdom published a report entitled "Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur". A total of 26 deaths had been reported to them when cement was used at hemiarthroplasty between October 2003 and October 2008. This paper considers the evidence for using cement fixation of a hemiarthroplasty in the treatment of hip fractures.

The Exeter Hip. 40 Years of Innovation in Total Hip Arthroplasty

* Propoerties and use of acrylic cement * Design and biomechaniscs of a cemented hip replacement * The science of loosening, lysis and wear * Preparation of patients for surgery * Potential complications and their avoidance * Modern primary surgical techniques and new developments * Complex primary hip replacement and specialist techniques * Outcomes of cemented hip replacement * Principles of revision hip replacement * Basic science of bone grafting in revision surgery * Femoral acetabular impaction bone grafting techniques * Results of revision with bone graft and cement