Orthopaedic Update

“Never believe the media at first hand!!-most times misinform the public creating confusion and unnecessary anxiety. Always do your own research and talk to your doctor or surgeon/s”

Updates on current orthopaedic news around the world.

References

Enhanced recovery after Joint replacement Surgery:

This is a programme aimed to reduce physical and psychological trauma of surgery and enhancing the process of recovery.

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Hip Section

Hip Replacement Reduces Heart Failure, Depression and Diabetes Risk

Study supports the value of THR in aiding long-term health at minimal cost
In addition to improving life quality and diminishing pain, total hip replacement (THR) is associated with reduced mortality, heart failure, depression and diabetes rates in Medicare patients with osteoarthritis, according to a new study presented at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons(AAOS)

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Study Outlines Risk Factors for Poor Outcome, Mortality Following Hip Fracture

Commencing surgery sooner may alleviate hip fracture complications

A new study, presented at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons(AAOS), identifies predictors of complications and mortality following a hip fracture, including dialysis, cardiac disease, diabetes, and a longer time before surgery – the only modifiable risk factor when patients are hospitalized.

Hypertension and diabetes were the most common medical comorbidities among patients.
“Reduced time to surgical intervention appears to be the single greatest factor with which a surgeon might influence the risk of mortality or complications,”

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Whats new in Hip Arthroscopic Surgery?

This is a rapidly growing area which requires specialized training. Currently this is available for many hip conditions either for diagnosing or treating hip joint conditions. FAI (femoro-acetabuar-impingement) either for CAM or Pincer lesions are common conditions where hip arthroscopy is used.

So is open or arthroscopic technique better?

The Mayo clinic in USA are conducting randomized clinical trials to evaluate which is beneficial to patients.

With experience and advanced instrumentation, areas around the hip can also be assessed like the hip abductors (gleuteusmedius and minimis)

Gluteus medius repairs can also be performed through hip arthroscopic techniques (providing the tendon is still in good condition and repairable to the site of insertion).

In the past the hip capsule during the arthroscopy used to be left open. This may lead to instabilities (there is still debate about this). Newer techniques/instrumentation enables to repair the capsule and stabilize the hip.

Internal Snapping Hip Syndrome: can be due to the iliopsoas tendon slippage over the femoral head or the iliopectineal eminence (on the pelvic bone). With advanced techniques the surgeon can pass through the central compartment of the hip during arthroscopy, create a small window and release this tendon. (this tendon is half muscle and half tendon at this level and its like lengthening a tendon as opposed to detachment)

Metal on Metal Revisited:

The majority of patients with metal on metal implants continue to do well and are at low risk of developing problems (MHRA UK).

However, a small number of patients with large metal on metal full hip replacements could develop complications.

MHRA (UK) issued updated patient management and monitoring advice to surgeons and doctors that they should monitor patients every year for the lifetime of their metal on metal total hip replacements sized 36 millimeters or above.

By monitoring patients every year, any complications will be picked up earlier and more complex surgery on the patient can be avoided.

During the June 2012 Orthopaedic and Rehabilitation Devices Advisory Panel meeting, the FDA reviewed available data and discussed the safety risks and effectiveness of metal-on-metal hip implants with patients, physicians, researchers, international regulatory agencies, professional societies, and manufacturers. Issues discussed included:

  • Failure rates and modes;
  • Metal ion testing;
  • Imaging methods;
  • Local and systemic complications;
  • Patient risk factors; and
  • Considerations for follow-up after surgery.

The FDA considered the input provided by the Panel members and is now providing updated safety information to patients and health care providers. The FDA will continue to gather and review available data on currently marketed metal-on-metal hip implants and will provide updates as necessary to patients and health care providers.
(FDA USA)

Questions and answers on metal on metal implants

Anteroir Hip replacement: whats the take on this:

Although most surgeons still use the posterior approach, the anterior hip replacements have re-emerged as a viable option. One advantage is doing it through smaller incisions with the use of specialized instruments.

It claims to be a muscle sparing approach, is this the case that it is just muscle splitting?

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Is there a learning curve for this approach?

The answer is yes, its is different to the traditional posterior approach which most surgeons use and a surgeon needs to be aware of spatial orientation especially with anatomical landmarks and when putting the components (cup and stem) in the correct orientation, that is inclination and anteversion (reducing the complications of joint dislocation) and also pay particular attention to Leg Length Discrepancies especially when using traction tables.

How many anterior hips does one have to be involved in before being confident?

Most surgeons say between 20-50, this depends from person to person and varies with versatility, ability to learn new techniques fast and being adaptive,

So do surgeons practice on patients?

The answer is NO. Surgeons usually go through rigorous training in these techniques, which usually start with clinical teaching, meetings, lectures, etc, followed by many intense cadaveric courses with hands on experience. Even after this most surgeons have more experienced surgeons usually helping out when they are starting to do this approach so the patient can actually get a good outcome.

Hip resurfacing: is it out of Fashion?

Hip resurfacings are still performed in younger more active individuals with arthritis of the hip who want to maintain an active lifestyle.

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Knee Section

Ninety-eight Percent of Total Knee Replacement Patients Return to Life, Work Following Surgery

Patients bike, hike and swim again after total hip replacement surgery
Ninety-eight percent of total knee replacement (TKR) patients who were working before surgery returned to work after surgery, and of those patients, 89 percent returned to their previous position, according to new research. presented at the2013 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). Another related study highlights the life-restoring outcomes of total hip replacement (THR)

  • Nearly 75 percent of patients (493) were employed during the three months prior to their TKR and 98 percent returned to work after surgery. Of these patients, 89 percent successfully returned to the job they had prior to surgery.
  • Approximately 13 percent of the patients had sedentary jobs; 11 percent, light jobs; 24 percent, medium; 23 percent, heavy; and, 29 percent very heavy.
  • According to work type the return to work rate was 95 percent among sedentary employees, 91 percent among those in jobs deemed light; 100 percent in medium jobs, 98 percent in heavy jobs, and 97 percent in very heavy jobs.

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Obesity Alone May Not Affect Knee Replacement Outcome or Increase Overall Complication Risk

Obese patients undergoing total knee replacement face longer hospital stays, higher related costs.

Obesity alone may not diminish outcomes or increase the risk of complications in total knee replacement (TKR) patients, according to two research studies presented today at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons(AAOS)

Total knee replacement in obese patients previously has been associated with increased post-operative complications and lower clinical function scores in multiple research studies.

Although increasing BMI was not associated with an overall increase in complication risk during the 90-day window, there was a higher rate of infection in obese patients.

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ACL Reconstruction: Graft Types and Selection:

The aim of ACL reconstruction with the most suitable graft is to get the best functional outcome, minimize morbidity, and avoid or reduce the chance of revision surgery.

One study claimed that the incidence of ACL rupture was 1 in 3500 people resulting in 95000 new ACL ruptures(in USA).

Despite studies over the last 15 years there still controversy as to which graft is better with equivalent outcomes when comparing the commonly used grafts.

But newer studies since 2012 suggest Allograft to be avoided in Athletes (<25yrs) due to high failure rate. (7.7x higher than autograft)

Common allografts used were Achilles Tendon, Hamstring Tendons, Patellar Tendons and semitendinosis tendons.

The main disadvantages of the allografts were cost of processing, took longer to incorporate(“bind”) with host bone and when sterilized with radiation, made the biomechanical properties weaker. The other concern is graft elongation and rupture.

The advantages of using an Allograft is : there is usually no donor site morbidity (pain and discomfort from donating the graft) and especially allografts are useful in multiple ligament reconstructions.

However using an autograft is not without its own problems. The autografts include: hamstring, Patellarand quadriceps tendons. There may be increased post operative pain from donor sites and complications from graft harvest.

Recent data also show that if the graft diameter is less than 8mm, then the risk of rupture is higher.

Patello Femoral (PF) Arthritis and Patellofemoral Arthroplasty (replacement)

This is another area that is growing. In the last 10 years good results have been achieved when people had Total knee replacement for patella femoral arthritis for severe pain. But the question here is a total knee more than is needed to restore ones mobility without pain? Especially in younger patients?

Patellofemoral arthroplasty can be useful in carefully selected patients when it is isolated to that part of the knee joint. This ideally spares the rest of the knee joint and only replaces the diseased part.

This way the patients can actually mobilize almost immediately after surgery and go home the next day.

So the ideal patient is one who has advanced isolated PF arthritis, with our without trochlea dysplasia, or when there is post traumatic PFJ arthritis.

Knee Joint replacements at a Glance: (AAOS meeting 2012)

In the USA atleastupto 750000 knee replacements are done of which may be 12% may have to be revised in future.

Patient Matched Total Knee Replacements: also called patient specific-Knee:

What is it? Is this really a custom made implant to suit each patients knees?

No is the answer!. And the implants certainly don’t come from Europe or America! It is actually the Instrumentation or the so called custom made “Cutting Blocks” that a tailored for each patient from MRI or CT scans – made in USA or Europe and flown across to Australia. So the patients actually have custom made cutting blocks but standard conventional knee replacements (off the shelf).

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Meniscal Repairs Vs Excising (partial removals)

Returning to Sporting activities after knee injuries

Hamstring Injuries:

These are common in athletes involved in jumping, sprinting, acceleration and deceleration.

Rick Factors: An athlete with previous injuries to the hamstring has a higher likelihood of rupture. Age (increased age), less flexibility of the hip, athletes who don’t regularly do hamstring stretching exercises and high body mass index are also at a higher risk of rupture.

Mechanism of Injury: Proximal hamstring strain is very common amongst these injuries. This happens at the musculo-tendinuous junction especially during eccentric hip flexion and knee extension.

Complete retracted tears in the proximal (buttock) regions are more often treated by surgical means. This can result in pain relief, good functional outcome, higher patient satisfaction and excellent healing rates.

Diagnosis: Patients who have a rupture (proximal) can sometimes feel a mass or a gap. They will need to see an orthopaedic specialist, and require, Xrays, MRI scans to confirm this.

Treatment: It is advocated that these injuries be treated surgically back to the ischial tuberosity.

The main risk during repairs is the Sciatic nerve, which needs to be identified and protected. Read more on repair:

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Complications of Not repairing include sciatic neuralgia (pain) and muscle
weakness.

After Care: After repair, patients are usually in a brace for upto 6 weeks with the knees flexed at 90 deg to protect repairs with physio and rehab. Surgical repairing enables athletes to return to sporting activities 60-85% of the time.

More articles:

Functional Results and Outcomes After Repair of Proximal Hamstring Avulsions

Posterior Hip Pain in an Athletic Population: Differential Diagnosis and Treatment Options

Proximal Hamstring Avulsion Injuries: A Technique Note on Surgical Repairs

Miscellaneous

Joint registries: gives good and accurate data (assuming they are entered and interpreted accurately). Apparently there was 5% reduction in revision rates after the start of joint registries.

In Australia the registry was established in 1999 but only in 2002 did it become fully national. But it is still a very important source of joint replacement information. The purpose of registries are for improving and maintaining quality of care and outcome in patients receiving these joint replacements.