Regional economic burden of revision total knee replacement: A cost-complexity analysis

BACKGROUND

GIRFT tasked regional networks with addressing case-load, complexity-spread and cost of revision knee replacement (KR), but the regional cost burden is not clear. The tariff for revision KR is currently not dependent on surgical complexity. 2 years of revision KR complexity data using the validated Revision Knee Complexity Classification (RKCC) checklist as a demonstration of complexity spread in the region has previously been published. The aims of this study were to estimate the annual regional cost of revision TKR using existing data, and estimate the cost/saving of complexity-clustering using existing data from 8 revision centres.

METHODS

Financial data from the regional high-volume centre for one year (2019) of RKCC data collection was obtained. Mean cost, tariff and balance was calculated for R1, R2 and R3 (RKCC), and applied to data from each revision centre to provide local estimates. Complexity clustering was considered using 3 hypothetical scenarios of high-volume centre absorbing R2s and/or R3s in place of R1s.

RESULTS

Mean net loss was £2,290.08 for R1s, £6,471.42 for R2s and £6,454.26 for R3s. The estimated total annual loss for the region was £1,005,025. Complexity-clustering was associated with greater losses; £162,918 for high-volume centre taking R2s and R3s, £37,477.60 for taking just R3s and £125,440 for taking just R2s.

CONCLUSION

Revision TKR surgery is expensive and insufficiently remunerated with current measures. Restructuring of regional workload would create additional financial burden on specialist centres with current tariff awards structure. Managing reimbursement at a regional or central level may help to incentivise compliance with GIRFT ideals.

Revision total knee replacement: A two-year review of complexity data and regional workload in South West England

BACKGROUND

The GIRFT report (2012) sought to address the need for sustainable orthopaedic treatment delivered through regional "networks"; the aim being improved care, decreased cost and reduced revision rate. The aims of this study were to record the number and complexity of revision total knee replacements within a regional network using a validated classification over a two-year period and audit this against National Joint Registry (NJR) records.

METHODS

A region-wide network model where revision TKR cases are assessed locally using the Revision Knee Complexity Classification (RKCC) and local multi-disciplinary team (MDT) was introduced. Data was collected from 8 revision centres over a two-year period using the RKCC. The case volume was audited against the NJR records.

RESULTS

In year 1 (01/01/2018-31/12/2018) 237 RKCC forms were collected from eight centres. 46% of R2s and 63% of R3s were carried out at the higher volume centre. 211 K2 forms were received by the NJR. In year 2 (01/01/2019-31/12/2019) 252 RKCC forms were collected. 46% of R2s and 64% of R3s were carried out at the higher volume centre. 267 K2 forms were received by the NJR.

CONCLUSION

This is the first published set of revision knee data showing complexity percentages across a region. The RKCC has been successfully introduced into the region and this has been sustained. The findings show that a successful network has been established and majority of complex revision knee surgery is occurring in the high-volume centre. NJR data suggests that the RKCC is capturing the complexity and volume of our work accurately.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BACKGROUND

Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.

AIM

To provide guidelines for surgeons and units delivering revision KR services.

METHODS

A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.

RESULTS

There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.

CONCLUSIONS

Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

BACKGROUND

The burden of knee replacement prosthetic joint infection (KR PJI) is increasing. KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions.

AIM

To provide guidelines for surgeons and units treating KR PJI.

METHODS

Guideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings.

RESULTS

Improved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT. This document outlines practice guidelines for units providing a KR PJI service and sets out: CONCLUSIONS: KR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.

Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery

PURPOSE

There is considerable variation in practice throughout Europe in both the services provided and in the outcomes of Revision Knee Surgery. In the UK, a recent report published called get it right first time (GIRFT) aims to improve patient outcomes through providing high quality, cost-effective care, and reducing complications. This has led to the development of a classification system that attempts to classify the complexity of revision knee surgery, aiming to encourage and support regional clinical networking.

METHODS

The revision knee classification system (RKCC) incorporates not only complexity, but also patient factors, the presence of infection, the integrity of the extensor mechanism, and the soft tissues. It then provides guidance for clinical network discussion. Reliability and reproducibility testing have been performed to establish the inter- and intra-observer variabilities using this classification.

RESULTS

Good correlation between first attempt non-expert and experts, good intra-observer variability of non-expert, and an excellent correlation between second attempt non-expert and experts has been achieved. This supports the use of RKCC by both inexperienced and experienced surgeons.

CONCLUSIONS

The revision knee complexity classification has been proposed that offers a common-sense approach to recognize the increasing complexity in revision TKR cases. It provides a methodological assessment of revision knee cases and support regional clinical networking and triage of appropriate cases to revision units or specialist centres.

LEVEL OF EVIDENCE

Expert opinion, Level V.

The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates: An experimental and finite element study

Objectives

Opening wedge high tibial osteotomy (HTO) is an established surgical procedure for the treatment of early-stage knee arthritis. Other than infection, the majority of complications are related to mechanical factors – in particular, stimulation of healing at the osteotomy site. This study used finite element (FE) analysis to investigate the effect of plate design and bridging span on interfragmentary movement (IFM) and the influence of fracture healing on plate stress and potential failure.

Materials and Methods

A 10° opening wedge HTO was created in a composite tibia. Imaging and strain gauge data were used to create and validate FE models. Models of an intact tibia and a tibia implanted with a custom HTO plate using two different bridging spans were validated against experimental data. Physiological muscle forces and different stages of osteotomy gap healing simulating up to six weeks postoperatively were then incorporated. Predictions of plate stress and IFM for the custom plate were compared against predictions for an industry standard plate (TomoFix).

Results

For both plate types, long spans increased IFM but did not substantially alter peak plate stress. The custom plate increased axial and shear IFM values by up to 24% and 47%, respectively, compared with the TomoFix. In all cases, a callus stiffness of 528 MPa was required to reduce plate stress below the fatigue strength of titanium alloy.

Conclusion

We demonstrate that larger bridging spans in opening wedge HTO increase IFM without substantially increasing plate stress. The results indicate, however, that callus healing is required to prevent fatigue failure.

Cite this article: A. R. MacLeod, G. Serrancoli, B. J. Fregly, A. D. Toms, H. S. Gill. The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates: An experimental and finite element study. Bone Joint Res 2018;7:639–649. DOI: 10.1302/2046-3758.712.BJR-2018-0035.R1.

Outcome of kinematic alignment using patient-specific instrumentation versus mechanical alignment in TKA: a meta-analysis and subgroup analysis of randomised trials

INTRODUCTION

Kinematic alignment (KA) in total knee arthroplasty (TKA) matches component position to the pre-arthritic anatomy of an individual patient, with the aim of improving functional outcomes. Recent randomised controlled trials (RCTs) comparing KA to traditional neutral mechanical alignment (MA) have been mixed. This collaborative study combined raw data from RCTs, aiming to compare functional outcomes between KA using patient-specific instrumentation (PSI) and MA, and whether any patient subgroups may benefit more from KA technique.

MATERIALS AND METHODS

A literature search in PubMed, EMBASE and Cochrane databases identified four randomised controlled trials comparing patients undergoing TKA using PSI-KA and MA. Unpublished data including Western Ontario McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS) were obtained from study authors. Meta-analysis compared MA to KA change (post-op minus pre-op) scores. Subgroup-analysis on KA patients looked for subgroups more likely to benefit from KA and the impact of PSI accuracy.

RESULTS

Meta-analyses of change scores in 229 KA patients versus 229 MA patients were no different from WOMAC (mean difference 3.4; 95% confidence interval - 0.5 to 7.3), KSS function (1.3, - 3.9 to 6.4) or KSS combined (7.2, - 0.8 to 15.2). A small advantage was seen for KSS pain in the KA group (3.6, 95% CI 0.2-7.1). Subgroup-analysis showed no difference between varus, valgus and neutral pre-operative alignment groups, and those who did and did not achieve KA plans. Pain-free patients at 1-year were more likely to achieve KA plans.

CONCLUSION

Patient-reported outcome scores following TKA using PSI-KA are similar to MA. No identifiable subgroups benefited more from KA, and long-term results remain unknown. Inaccuracy of the PSI system used in KA patients could potentially affect outcome.

The largest survivorship and clinical outcomes study of the fixed bearing Stryker Triathlon Partial Knee Replacement - A multi-surgeon, single centre cohort study with a minimum of two years of follow-up

BACKGROUND

The surgical management of isolated medial compartment degenerative disease of the knee causes debate. Unicompartmental arthroplasty options include fixed and mobile bearing implant designs with fixed bearing becoming increasingly popular. We present the largest cohort of a fixed bearing single radius design, Stryker Triathlon Partial Knee Replacement (PKR).

METHODS

We prospectively collected demographic data and patient reported outcome measures (PROMs) on our cohort of PKR implants since its adoption in our unit, 2009 until March 2015.

RESULTS

A total of 129 implants in 115 patients with a mean follow-up of 5.5 years (2.5 to 8.5 years) were included. There were 11 revisions at an average of 1.7 years (0.6-4.1 years), two for infection, two for mal-alignment, five for progression of disease and two for loosening. The survivorship of the implants at five years is 90%.

CONCLUSION

The PKR provides good survivorship at five years and PROM scores that are equal to the largest and most popular comparable implants. There is an associated learning curve with this implant, as there is with all systems and this is reflected in our results.

Disuse osteopenia following leg fracture in postmenopausal women: Implications for HIP fracture risk and fracture liaison services

INTRODUCTION

Disuse osteopenia is a known consequence of reduced weight-bearing and has been demonstrated at the hip following leg injury but has not been specifically studied in postmenopausal women.

METHOD

Bilateral DXA (GE Lunar Prodigy) bone mineral density (BMD) measurements were taken at the neck of femur (NOF), total hip region (TH) and lumbar spine in postmenopausal female groups comprising controls (N = 43), new leg fractures (#<3wks) (N = 9), and participants who had sustained a leg fracture more than one year previously (#>1yr) (N = 24). #>1yr were assessed at a single visit and the remaining groups at intervals over twelve months. Weight-bearing, function, 3-day pedometer readings, and pain levels were also recorded.

RESULTS

The #<3wks demonstrated significant (p < 0.05) losses in ipsilateral TH BMD at 6 weeks from baseline 0.927 ± 0.137 g/cm², to 0.916 ± 0.151 g/cm² improving to 0.946 ± 0.135 g/cm² (n.s) at 12 months following gradual return to normal function and weight-bearing activity. The #>1yr scored significantly below controls in almost all key physical and functional outcomes demonstrating a long-term deficit in hip bone density on the ipsilateral side.

CONCLUSION

The clinical significance of post-fracture reduction in hip BMD is a potential increased risk of hip fracture for a variable period that may be mitigated after return to normal function and weight-bearing. Improvement at 12 months in #<3wks is not consistent with #>1yr results indicating that long-term impairment in function and bone health may persist for some leg fracture patients. Unilateral bone loss could have implications for Fracture Liaison Services when assessing the requirement for medication post fracture.

The early outcome of kinematic versus mechanical alignment in total knee arthroplasty: a prospective randomised control trial

AIMS

Our aim was to compare kinematic with mechanical alignment in total knee arthroplasty (TKA).

PATIENTS AND METHODS

We performed a prospective blinded randomised controlled trial to compare the functional outcome of patients undergoing TKA in mechanical alignment (MA) with those in kinematic alignment (KA). A total of 71 patients undergoing TKA were randomised to either kinematic (n = 36) or mechanical alignment (n = 35). Pre- and post-operative hip-knee-ankle radiographs were analysed. The knee injury and osteoarthritis outcome score (KOOS), American Knee Society Score, Short Form-36, Euro-Qol (EQ-5D), range of movement (ROM), two minute walk, and timed up and go tests were assessed pre-operatively and at six weeks, three and six months and one year post-operatively.

RESULTS

A total of 78% of the kinematically aligned group (28 patients) and 77% of the mechanically aligned group (27 patients) were within 3° of their pre-operative plan. There were no statistically significant differences in the mean KOOS (difference 1.3, 95% confidence interval (CI) -9.4 to 12.1, p = 0.80), EQ-5D (difference 0.8, 95% CI -7.9 to 9.6, p = 0.84), ROM (difference 0.1, 95% CI -6.0 to 6.1, p = 0.99), two minute distance tolerance (difference 20.0, 95% CI -52.8 to 92.8, p = 0.58), or timed up and go (difference 0.78, 95% CI -2.3 to 3.9, p = 0.62) between the groups at one year.

CONCLUSION

Kinematically aligned TKAs appear to have comparable short-term results to mechanically aligned TKAs with no significant differences in function one year post-operatively. Further research is required to see if any theoretical long-term functional benefits of kinematic alignment are realised or if there are any potential effects on implant survival. Cite this article: Bone Joint J 2016;98-B:1360-8.

A study investigating short- and medium-term effects on function, bone mineral density and lean tissue mass post-total knee replacement in a Caucasian female post-menopausal population: implications for hip fracture risk

Significant increased hip fracture incidence has been reported in the year following total knee replacement. This study demonstrates that bone and muscle loss is a post-surgical consequence of total knee replacement, alongside poor outcomes in function and activity potentially contributing to reduced quality of life and increased hip fracture risk.

INTRODUCTION

A significant increase in hip fracture incidence in the year following total knee replacement (TKR) surgery has been reported. This study investigated function and activity following TKR and the effects of limited mobility on bone and muscle loss and their potential contribution to hip fracture risk.

METHODS

Changes in dual-energy X-ray absorptiometry (DXA) (GE Lunar Prodigy, Bedford MA), bone mineral density (BMD) at the neck of femur (NOF), total hip region (TH) and lumbar spine were measured alongside leg lean tissue mass (LLTM) in post-menopausal Caucasian females following TKR (N = 19) compared to controls (N = 43). Lumbar spine trabecular bone scores (TBSs) were calculated. Ipsilateral/contralateral weight bearing, lower limb function, 3-day pedometer readings, pain levels and falls were also recorded. Measurements were obtained at pre-surgery baseline and at 6 weeks, 6 months and 12 months post-surgery.

RESULTS

No statistically significant differences were demonstrated between groups at baseline bilaterally in LLTM or BMD at the NOF and TH. Losses in ipsilateral NOF and TH BMD and contralateral LLTM were significantly higher in the TKR group at 6 months. Impairment in function and weight bearing persisted in the TKR group 12 months post-operatively alongside deficits in bilateral muscle mass and ipsilateral NOF and TH BMD. Falls incidence was not significantly higher in the TKR group.

CONCLUSIONS

Bone loss at the hip with associated muscle loss is a consequence of TKR that, in addition to poor patient outcomes in function and activity, potentially contributes to increased hip fracture risk in the year following surgery.

Rationing of orthopaedic surgery in the UK

The global economy has been facing a financial crisis. Healthcare costs are spiraling, and there is a projected £30 billion health funding gap by 2020 in the UK. 1 This has prompted a drive for efficiency in healthcare provision in the UK, and in 2012, the Health and Social Care Act was introduced, heralding a fundamental change to the structure of the National Health Service, especially in the way that healthcare is funded in England. 2

What is happening in the UK is a reflection of a global problem. Rationing of healthcare is a topic of much discussion; as unless spending is capped, providing healthcare will become unsustainable. Who decides how money is spent, and which services should be rationed?

In this article we aim to discuss the impact that rationing may have on orthopaedic surgery, and we will discuss our own experiences of attempts to ration local services. 3 We also seek to inform and educate the general orthopaedic community on this topic.

The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the National Joint Registry dataset

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are recognised and proven interventions for patients with advanced arthritis. Studies to date have demonstrated a steady increase in the requirement for primary and revision procedures. Projected estimates made for the United States show that by 2030 the demand for primary TKA will grow by 673% and for revision TKA by 601% from the level in 2005. For THA the projected estimates are 174% and 137% for primary and revision surgery, respectively. The purpose of this study was to see if those predictions were similar for England and Wales using data from the National Joint Registry and the Office of National Statistics. Analysis of data for England and Wales suggest that by 2030, the volume of primary and revision TKAs will have increased by 117% and 332%, respectively between 2012 and 2030. The data for the United States translates to a 306% cumulative rate of increase between 2012 and 2030 for revision surgery, which is similar to our predictions for England and Wales. The predictions from the United States for primary TKA were similar to our upper limit projections. For THA, we predicted an increase of 134% and 31% for primary and revision hip surgery, respectively. Our model has limitations, however, it highlights the economic burden of arthroplasty in the future in England and Wales as a real and unaddressed problem. This will have significant implications for the provision of health care and the management of orthopaedic services in the future.

The natural history of pain and neuropathic pain after knee replacement: a prospective cohort study of the point prevalence of pain and neuropathic pain to a minimum three-year follow-up

A small proportion of patients have persistent pain after total knee replacement (TKR). The primary aim of this study was to record the prevalence of pain after TKR at specific intervals post-operatively and to ascertain the impact of neuropathic pain. The secondary aim was to establish any predictive factors that could be used to identify patients who were likely to have high levels of pain or neuropathic pain after TKR. A total of 96 patients were included in the study. Their mean age was 71 years (48 to 89); 54 (56%) were female. The mean follow-up was 46 months (39 to 51). Pre-operative demographic details were recorded including a Visual Analogue Score (VAS) for pain, the Hospital Anxiety and Depression score as well as the painDETECT score for neuropathic pain. Functional outcome was assessed using the Oxford Knee score. The mean pre-operative VAS was 5.8 (1 to 10); and it improved significantly at all time periods post-operatively (p < 0.001): (from 4.5 at day three to five (1 to 10), 3.2 at six weeks (0 to 9), 2.4 at three months (0 to 7), 2.0 at six months (0 to 9), 1.7 at nine months (0 to 9), 1.5 at one year (0 to 8) and 2.0 at mean 46 months (0 to 10)). There was a high correlation (r > 0.7; p < 0.001) between the mean VAS scores for pain and the mean painDETECT scores at three months, one year and three years post-operatively. There was no correlation between the pre-operative scores and any post-operative scores at any time point. We report the prevalence of pain and neuropathic pain at various intervals up to three years after TKR. Neuropathic pain is an underestimated problem in patients with pain after TKR. It peaks at between six weeks and three-months post-operatively. However, from these data we were unable to predict which patients are most likely to be affected.

Salmonella infection of a total knee replacement

Salmonella enterica serotype Choleraesuis is a rare infective pathogen in total knee arthroplasty and accounts for less than 1% of all cases. In the United Kingdom, the most prevalent organisms are Staphylococci, which account for over 50% of cases. We present an interesting case report of an infected revision total knee replacement following foreign travel to a region with an increased prevalence of Salmonella. The patient presented typically with an effused knee and raised inflammatory markers. Tissue samples demonstrated Salmonella choleraesuis as the infective organism. Though this serotype has previously been isolated from an infected total hip prosthesis, we believe this could be the first reported case involving a total knee replacement. Following involvement of our microbiology team and aggressive antibiotic therapy, the patient was successfully treated with two-stage revision surgery and at one-year post-op is making a satisfactory recovery.

The management of patients with painful total knee replacement

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient's pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

Repair of defects and containment in revision total knee replacement

The treatment of bony defects of the tibia at the time of revision total knee replacement is controversial. The place of compacted morsellised bone graft is becoming established, particularly in contained defects. It has previously been shown that the initial stability of impaction-grafted trays in the contained defects is equivalent to that of an uncemented primary knee replacement. However, there is little biomechanical evidence on which to base a decision in the treatment of uncontained defects. We undertook a laboratory-based biomechanical study comparing three methods of graft containment in segmental medial tibial defects and compared them with the use of a modular metal augment to bypass the defect.

Using resin models of the proximal tibia with medial defects representing either 46% or 65% of the medial cortical rim, repair of the defect was accomplished using mesh, cement or a novel bag technique, after which impaction bone grafting was used to fill the contained defects and a tibial component was cemented in place. As a control, a cemented tibial component with modular metal augments was used in identical defects. All specimens were submitted to cyclical mechanical loading, during which cyclical and permanent tray displacement were determined.

The results showed satisfactory stability with all the techniques except the bone bag method. Using metal augments gave the highest initial stability, but obviously lacked any potential for bone restoration.

The management of bone loss in revision total knee replacement

The management of bone loss in revision replacement of the knee remains a challenge despite an array of options available to the surgeon. Bone loss may occur as a result of the original disease, the design of the prosthesis, the mechanism of failure or technical error at initial surgery. The aim of revision surgery is to relieve pain and improve function while addressing the mechanism of failure in order to reconstruct a stable platform with transfer of load to the host bone. Methods of reconstruction include the use of cement, modular metal augmentation of prostheses, custom-made, tumour-type or hinged implants and bone grafting. The published results of the surgical techniques are summarised and a guide for the management of bone defects in revision surgery of the knee is presented.

Evaluation of patients with a painful total knee replacement

Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.

Mechanical testing of impaction bone grafting in the tibia

Clinical experience of impaction bone grafting for revision knee arthroplasty is limited, with initial stability of the tibial tray emerging as a major concern. The length of the stem and its diameter have been altered to improve stability. Our aim was to investigate the effect of the type of stem, support of the rim and graft impaction on early stability of the tray.

We developed a system for impaction grafting of trays which we used with morsellised bone in artificial tibiae. Trays with short, long thick or long thin stems were implanted, with or without support of the rim. They were cyclically loaded while measuring relative movement.

Long-stemmed trays migrated 4.5 times less than short-stemmed trays, regardless of diameter. Those with support migrated 2.8 times less than those without. The migration of short-stemmed trays correlated inversely with the density of the impacted groups. That of impaction-grafted tibial trays was in the range reported for uncemented primary trays. Movements of short-stemmed trays without cortical support were largest and sensitive to the degree of compaction of the graft. If support of the rim was sufficient or a long stem was used, impacted morsellised bone graft achieved adequate initial stability.

Metastatic bone disease--the orthopaedic workload

BACKGROUND

In 1999, the British Association of Surgical Oncology (BASO) published its guidelines for the management of metastatic bone disease in breast cancer in the UK, highlighting the role of the orthopaedic surgeon as an integral part of the multidisciplinary team.

AIM

To establish the workload to our department of metastatic bone disease.

METHODS

A prospective study was performed over a 6-month period aiming to study factors affecting length of stay, whether BASO recommendations were being adhered to for metastatic breast disease and whether BASO recommendations could be extended to other forms of metastatic bone disease.

RESULTS

36 patients were referred to the orthopaedic department during the study period. The majority of the patients were referred as emergencies, 83% of patients were seen by an orthopaedic consultant on the day of referral but only 27% were seen by the orthopaedic cancer liaison consultant. Only 16 patients required a therapeutic operative intervention and length of in-patient stay was increased by not having a known primary carcinoma at admission. Patients with bone metastases discussed at the breast cancer multidisciplinary meeting were also studied as were patients with bone metastases presenting to the oncology service. It was found that there was little overlap between these groups and our study group.

CONCLUSIONS

Metastatic bone disease does form a workload to the orthopaedic department and BASO recommendations are generally followed for breast disease. The BASO recommendations could be extended to other tumours; however, it should be recognised that there is a significant workload involved and a need for sufficient resources to allow a high quality and timely service.

The current management of tibial fractures: are clinical guidelines effective?

BACKGROUND

The production of clinical guidelines is increasing and will continue to do so with the introduction of clinical governance. In 1997, the British Orthopaedic Association (BOA) and the British Association of Plastic Surgeons (BAPS) published joint guidelines on the management of open tibial fractures. It is not known whether these guidelines reached their target audience, or indeed influenced clinical practice.

METHODS

We determined the effectiveness of these guidelines by sending a postal questionnaire survey to 172 orthopaedic surgeons.

RESULTS

Only 57% of consultants were aware of the guidelines, 70% of registrars and 25% of staff grades. Less than 29% of orthopaedic consultants would choose to consult the plastic surgical team pre-operatively in the management of an open tibial fracture and only 43% would seek plastic surgical involvement at all. The primary aim of increasing multidisciplinary communication has not been achieved.

CONCLUSIONS

The awareness of, and adherence to, these guidelines is sub-optimal. This clearly has implications for both the future management of open tibial fractures and the further production of guidelines.

The evidence base on the orthopaedic NICE report

Since the publication of its first guidelines the National Institute for Clinical Excellence (NICE) has come under a lot of criticism, particularly with respect to its recommendations in medicine (Bratby, 2001). The first appraisal in the field of surgery was on total hip replacement (THR) and was issued in April 2000 (NICE, 2000).

Analysis of the Leeds-Keio ligament for extensor mechanism repair: favourable mechanical and functional outcome

Many techniques have been described for the challenging problem of extensor mechanism rupture, including the use of synthetic grafts. In 1994 Fujikawa et al. [J. Bone Surg. 1994:76B:200-203] reported excellent results using the Leeds-Keio polyester ligament. Patients were mobilised early, had few post operative complications and minimal extensor lag. This is the first independent assessment of this technique using both subjective and objective analysis of outcome. We reviewed 11 patients (12 knees) whose extensor mechanisms were repaired as described in the original paper. At a mean of 3 years after surgery there were no infections and no re-ruptures. Good functional recovery was observed with a mean Tegner activity score of 1.7, Lysholm score of 66 and Irrgang score of 58%. Indeed, 80% of working patients returned to their former employment. However, objective tests showed peak extensor torque recovered to only half normal strength. We conclude the results of this technique of repair compare favourably with other described techniques especially in complex cases.

Nice hips: shame about the conclusions

In April 2000 the National Institute for Clinical Excellence (NICE) issued their first appraisal in the field of surgery, "Guidance on the selection of prostheses for primary total hip replacement". NICE has already been heavily criticised for its recommendations in the field of medicine, due to its perceived role in rationing healthcare. This paper examines the conclusions of the appraisal committee (which included only two orthopaedic surgeons), the evidence on which they drew their conclusions and the evidence that was overlooked. We conclude that it is not clear how they determined the important ten-year benchmark and that they over-emphasise the benefits of cheaper cemented prostheses, failing to fully consider the evidence for the more expensive uncemented and hybrid combinations. (Hip International 2002; 12: 334-7).

Intramedullary femoral nailing: removing the nail improves subjective outcome

Intramedullary nailing has become an established treatment for femoral fractures. We reviewed the subjective and objective outcome of locked intramedullary nailing since its introduction to our unit in 1988. The outcome was assessed subjectively using the Short Form 36 (SF 36) health questionnaire and objectively by clinical, radiological and case note review. From 1988 to 1995, 220 intramedullary femoral nails were inserted at the North Staffordshire Royal Infirmary. Of these we were able to match the SF 36 questionnaire and case review of 91 patients. Fifty-six patients were male and 35 female with an average age of 40. Acute trauma accounted for 86 cases (six with an injury severity score >15 and seven open injuries). There was a 24% incidence of minor complications; there were no deep infections and no major complications. All cases recorded subjective scores within the normal range but 34 symptomatic patients who had their femoral nails removed (mainly for persistent pain or prominent metalwork) recorded noticeably higher scores in all eight assessment areas. Intramedullary nailing for femoral fractures is a technically demanding procedure and results in both a good objective and subjective outcome. It is associated with a low rate of major complications but a relatively high rate of minor complications. We conclude that the removal of intramedullary femoral nails is justified in symptomatic patients. It results in an improved subjective outcome and has a low complication rate.

Mountain biking injuries in rural England

BACKGROUND

Off road mountain biking is now an extremely popular recreation and a potent cause of serious injury.

AIM

To establish the morbidity associated with this sport.

METHODS

Data were collected prospectively over one year on all patients presenting with an injury caused by either recreational or competitive off road mountain biking.

RESULTS

Eighty four patients were identified, 70 males and 14 females, with a mean age of 22.5 years (range 8-71). Most accidents occurred during the summer months, most commonly in August. Each patient had an average of 1.6 injuries (n = 133) and these were divided into 15 categories, ranging from minor soft tissue to potentially life threatening. Operative intervention was indicated for 19 patients (23%) and several required multiple procedures. The commonest injuries were clavicle fractures (13%), shoulder injuries (12%), and distal radial fractures (11%). However, of a more sinister nature, one patient had a C2/3 dislocation requiring urgent stabilisation, one required a chest drain for a haemopneumothorax, and another required an emergency and life saving nephrectomy.

CONCLUSION

This sport has recently experienced an explosion in popularity, and, as it carries a significant risk of potentially life threatening injury across all levels of participation, the use of protective equipment to reduce this significant morbidity may be advisable.

Obturator dislocation of the hip

We describe two patients with obturator dislocation of the hip which was irreducible by described techniques of closed reduction. The first required open reduction using the iliofemoral approach with release of rectus femoris. The second was treated on a traction table which allowed disengagement of the head and, when combined with simultaneous lateral traction, adduction and gradual release of the longitudinal traction, facilitated a smooth reduction. Since the hip is stable in flexion, early mobilisation in an extension-limiting brace avoids the prolonged bed rest traditionally recommended for this injury.