Joint replacement of the hip and knee remain very satisfactory operations. They are, however, expensive. The actual manufacturing of the implant represents only 30% of the final cost, while sales and marketing represent 40%. Recently, the patents on many well established and successful implants have expired. Companies have started producing and distributing implants that purport to replicate existing implants with good long-term results. The aims of this paper are to assess the legality, the monitoring and cost saving implications of such generic implants. We also assess how this might affect the traditional orthopaedic implant companies. Cite this article: Bone Joint J 2016;98-B:892-900.
Reported rates of dislocation in hip hemiarthroplasty (HA) for the treatment of intra-capsular fractures of the hip, range between 1% and 10%. HA is frequently performed through a direct lateral surgical approach. The aim of this study is to determine the contribution of the anterior capsule to the stability of a cemented HA through a direct lateral approach. A total of five whole-body cadavers were thawed at room temperature, providing ten hip joints for investigation. A Thompson HA was cemented in place via a direct lateral approach. The cadavers were then positioned supine, both knee joints were disarticulated and a digital torque wrench was attached to the femur using a circular frame with three half pins. The wrench applied an external rotation force with the hip in extension to allow the hip to dislocate anteriorly. Each hip was dislocated twice; once with a capsular repair and once without repairing the capsule. Stratified sampling ensured the order in which this was performed was alternated for the paired hips on each cadaver. Comparing peak torque force in hips with the capsule repaired and peak torque force in hips without repair of the capsule, revealed a significant difference between the ‘capsule repaired’ (mean 22.96 Nm, standard deviation (sd) 4.61) and the ‘capsule not repaired’ group (mean 5.6 Nm, sd 2.81) (p < 0.001). Capsular repair may help reduce the risk of hip dislocation following HA. Cite this article: Bone Joint J 2015;97-B:141–4.
For CT coronary angiography (CTCA), a generic chest conversion factor returns a significant underestimate of effective dose. The aim of this manuscript is to communicate new dosimetry methods to calculate weighted CT dose index (CTDIw), effective dose, entrance surface dose (ESD) and organ dose to the breast for prospectively gated CTCA.CTDIw in 32 cm diameter Perspex phantom was measured using an adapted technique, accounting for the segmented scan characteristic. Gafchromic XRCT film (International Speciality Products, New Jersey, NJ) was used to measure the distribution and magnitude of ESD. Breast dose was measured using high sensitivity metal oxide semiconductor field-effect transistors and compared to the computer based imaging performance assessment of CT scanners (ImPACT) dosimetry calculations.For a typical cardiac scan the mean ESD remained broadly constant (7-9 mGy) when averaged over the circumference of the Perspex phantom. Typical absorbed dose to the breast with prospectively gated protocols was within the range 2-15 mGy. The subsequent lifetime attributable risk (LAR) of cancer incidence to the breast was found at 0.01-0.06 for a 20-year-old female. This compares favourably to 100 mGy (LAR ~0.43) for a retrospectively gated CTCA.Care must be taken when considering radiation dosimetry associated with prospectively gated scanning for CTCA and a method has been conveyed to account for this. Breast doses for prospectively gated CTCA are an order of magnitude lower than retrospectively gated scans. Optimisation of cardiac protocols is expected to show further dose reduction.
Primary pyomyositis is a rare bacterial infection of the skeletal muscle. Traditionally a tropical disease, it is increasingly described in westernised urban populations. The aetiology is due to transient bacteraemia in the presence of risk factors such as traumatised muscle, or immunocompromise. The condition presents in one of three stages, representing progression of disease severity. Intravenous antibiotic therapy is often sufficient for this disease at its early stage, but surgical drainage is necessary for advanced presentations. We report a severe case of stage 3 pyomyositis of the gluteus minimus, which led to Staphylococcus aureus sepsis, deranged liver function, acute kidney injury, autoanticoagulation and proximal femoral osteomyelitis in a healthy 64-year-old Caucasian man. This illustrates the potential severity of the disease, the life-threatening sequelae when diagnosis is delayed and the role of surgical drainage in averting the progression of systemic sepsis to end-organ dysfunction, disseminated intravascular coagulation and potentially death.
In 2011 health policy dictated a reduction in iatrogenic infections, such as Clostridium difficile (C. diff), this resulted in local change to antimicrobial policy in orthopaedic surgery. Previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change an increased number of patients appeared to suffer from acute kidney injury (AKI). We initially evaluated the incidence of AKI pre and post antibiotic change and found a correlation between the Flucloxacillin and AKI. We then made changes to antibiotic policy to mitigate the increased rates of AKI and proceeded to evaluate the outcomes.In this prospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data obtained. The degree of AKI was classified according to the validated RIFILE criteria.Evaluation showed a 4 fold decrease, from 13% to only 3%, in AKI after introduction of the modified antibiotic policy. C.difficile continues to be ...
The prevalence of left ventricular systolic dysfunction (LVSD) continues to rise. It is recognised that optimal medical therapy can improve ejection fraction (EF) in a proportion of patients. A nurse-led Heart Failure Service (HFS) was established in a district general hospital to deliver this, and previous analysis has demonstrated its efficacy in optimising HF drugs to recognised therapeutic doses. Complex devices (Implantable Cardiac Defibrillators [ICDs] or Cardiac Re-synchronisation Therapy Devices [CRTs]) are established treatments for HF patients if on Optimal Medical Therapy (OMT). The European Society of Cardiology (ESC) and National Institute for Clinical Excellence (NICE) guidelines have expanded their role with a broad cohort of patients eligible for this therapy.
Aim
We sought to determine how many patients, who at baseline had an indication for device therapy, improved after OMT to an extent that they no longer had an indication for device therapy.
Methods
A retrospective analysis was undertaken of the HFS database over a 5 year period recording ECG for QRS duration & morphology, surveillance of EF, device outcome. Exclusion criteria: baseline EF >35%; device in-situ or listed for prior to HFS referral; no identifiable baseline EF or ECG.
Results
502 patients were analysed and 264 patients met criteria for a new device or upgrade at baseline – 191 male (72%), 73 female (28%), median age 73 (IQR 64 – 80). 76/97 (78%) of potential CRT candidates (Pacing or Defibrillator component) were male. 16/97 (16%) improved to an EF >35% (median age 68 [IQR 64–72], 14 male [88%], 2 female [12%]). 4/16 (25%) of these patients underwent pharmacological or electrical cardioversion, which can contribute to EF improvement. There were 167 potential ICD candidates (115 male [69%]). 53/167 (32%) improved to an EF >35% (median age 68 [IQR 56–75], 33 male [61%]). 7/53 (13%) of these patients had other treatments that can also improve EF (cardioversion, 4; re-vascularisation, 2; valvuloplasty,1). 69/264 (26.1%) patients did not require a device after optimal therapy had been delivered.
Conclusion
We have demonstrated that in a significant proportion of HFS patients, the delivery of high quality OMT translates into an improvement in EF. Not all patients that strictly 'meet guideline criteria' will be offered a device, nor will all patients take up offer of a device. However, this improvement in EF is likely to benefit the patient symptomatically and prognostically, and carry a significant cost saving to healthcare institutions. A cost analysis study will be undertaken to further assess this.
Minimisation of radiation exposure during cardiac procedures is required by statute (IRMER 2000). During coronary angioplasty 47% of radiation dose is related to screening at standard frame rate (15 frames per second). Digital fluoroscopic technology has improved imaging making the use of lower frame rates feasible. This study assessed whether low frame rate screening (7.5 frames per second) reduced radiation without affecting patient outcomes.
Method
We prospectively collected data from consecutive coronary angioplasty procedures performed at reduced screening frame rate (7.5 frames per second). We included elective, urgent and emergency procedures. Audit data from procedures performed at standard frame rate with the same inclusion criteria were used as a control group. Phillips Allura flat plate XPER FD10 catheterisation equipment was used. The frame rate could be increased at the operator9s request, and any safety concerns were reported immediately.
Data collection
Patient data: Age Weight (Kg) Height (cm) Radiation data: Screening DAP (mGycm2) Total DAP (mGycm2) Total Fluoroscopy time (mm:ss) Number of acquisition runs Operator outcome: Need to increase screening frame rate Patient outcome: 30 day incidence of major adverse cardiovascular event (MACE): death, non-fatal myocardial infarction or need for urgent revascularisation.
Results
55 consecutive studies were examined at low-frame rate and compared with the audit control group (n=105). Mean age was 67 in the low screening rate group and 65 in the control group. Weight was similar in both groups (83 kg vs 82 kg). The screening times and number of acquisition runs were similar in each group. In every case image quality was acceptable, with no requirement for increased screening frame rate. No safety concerns were reported. 30-day incidence of major adverse cardiovascular events (MACE) was similar in both groups. In the screening group there was 1 MACE event at 30 days (2%), with 2 MACE events (2%) in the control group. Screening and Total DAPs (mean mGycm2) were 33% and 16% lower respectively in the low frame rate group. Statistical comparison was made with the Man-Whitney U-test. This showed a significant reduction in the Screening DAP (p≤0.01) with low frame rate screening. See Abstract 28 table 1 and graph.
Conclusions
Low frame rate screening is a practical way of reducing radiation exposure in line with the ALARA “As Low As Reasonably Acheivable” principle. Having shown that low frame rate screening for coronary angiography gives good imaging quality and is safe, we now demonstrate that low frame rate screening coronary angioplasty is also safe. Radiation exposure from screening is significantly reduced by 33% and total exposure is reduced by 16%. Low frame rate screening should be standard practice where modern facilities allow. We suggest that centres currently using 15 frames per second screening should undertake a similar assessment in order to minimise radiation.
Background: The major joint registries report better survivorship for ceramic on polyethylene over metal on polyethylene bearings in total hip arthroplasty and it is generally accepted that this is due to a lower polyethylene wear rate. We used evidence synthesis to compare survivorship, polyethylene wear rates and metal ion levels for metal-on-polyethylene (MoP) and ceramic-on-polyethylene (CoP) bearings. If wear rates are not dissimilar in vivo this difference in revision rate may have another cause. Modular junctions are a potential source of corrosion and it is postulated that this may result in higher revision rates. Methods: We performed a systematic review and meta-analysis comparing the survivorship of MoP and CoP bearings. Odds ratio (95% CI) of revision was calculated. Mean difference (MD) and 95% confidence intervals (CI) were used to compare secondary outcomes of polyethylene wear and metal ion levels. Meta-analysis was performed with a Mantel-Haenszel Random-Effects Model. Results: 6 randomised controlled trials were included. There was no statistically significant difference between MoP and CoP revision rate (OR 1.04; 95% CI, 0.37–2.90, I 2 = 0%, p = 0.94), linear bearing wear (MD 0.00 mm; 95% CI, −0.05 –0.05, I 2 = 98%, p = 0.90), nor volumetric bearing wear (MD 33.57 mm 3 ; 95% CI, −215.56–282.70, I 2 = 98%, p = 0.79). No studies evaluated metal ion levels. Conclusions: We found no evidence of a difference in revision rates nor linear and volumetric wear between MoP and CoP bearings in the randomised controlled trials currently available. Our study therefore does not advocate the additional cost associated with the use of ceramic heads in combination with polyethylene bearings in order to minimise revision rates. This contrasts the findings of in vitro studies and the major joint registries.
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