A hip replacement is a common type of surgery where a damaged hip joint is replaced with an artificial one (known as an implant). Adults of any age can be considered for a hip replacement, although most are done on people between the ages of 60 and 80. A modern artificial hip joint is designed to last for at least 15 years. Most people have a significant reduction in pain and improvement in their range of movement. When a hip replacement is needed Hip replacement surgery is usually necessary when the hip joint is worn or damaged so that your mobility is reduced and you are in pain even while resting. The most common reason for hip replacement surgery is osteoarthritis. Other conditions that can cause hip joint damage include: Rheumatoid arthritis Hip fracture Septic arthritis Disorders that cause unusual bone growth (bone dysplasia) Who is offered hip replacement surgery? A hip replacement is a major surgery, so it is usually only recommended if other treatments, such as physiotherapy or steroid injections, have not helped reduce pain or improve mobility. You may be offered hip replacement surgery if: You have severe pain, swelling and stiffness in your hip joint, and your mobility is reduced Your hip pain is so severe that it interferes with your quality of life and sleep Everyday tasks, such as shopping or getting out of the bath, are difficult or impossible You're feeling depressed because of the pain and lack of mobility You cannot work or have a social life You'll also need to be well enough to cope with both a major operation and the rehabilitation afterwards. How hip replacement surgery is performed A hip replacement can be done under a general anaesthetic (where you're asleep during the operation) or under a spinal anaesthetic (where you're awake but have no feeling from the waist down). Sometimes you may have an epidural, which is similar to a spinal anaesthetic. The surgeon makes a cut (incision) into the hip, removes the damaged hip joint and replaces it with an artificial joint or implant. The surgery usually takes around 1 to 2 hours to complete. Find out more about how a hip replacement is done. Hip resurfacing Hip resurfacing is an alternative type of operation. This involves removing the damaged surfaces of the bones inside the hip joint and replacing them with a metal surface. This type of operation removes less bone. However, it is usually only done on men who are very active and have larger hips. Resurfacing is much less popular now due to concerns about the metal surface causing damage to soft tissues around the hip. Preparing for hip replacement surgery Before you go into hospital, find out as much as you can about what's involved in your operation. Your hospital should provide written information or videos. Stay as active as you can. Strengthening the muscles around your hip will help your recovery. If you can, continue to do gentle exercise, such as walking and swimming, in the weeks and months before your operation. You may be referred to a physiotherapist, who will give you helpful exercises. Your hospital may offer an enhanced recovery programme. This rehabilitation programme aims to get you back to full health quickly after major surgery. Find out more about preparing for surgery, including information on travel arrangements, what to bring with you and attending a pre-operative assessment. Recovering from hip replacement surgery You'll usually be in hospital for 3 to 5 days, but recovery time can vary. Once you're ready to be discharged, your hospital will give you advice about looking after your hip at home. You'll need to use a frame or crutches at first and a physiotherapist will teach you exercises to help strengthen your hip muscles. An occupational therapist will check if you need any equipment to help you manage at home. You may also be enrolled in an exercise programme that's designed to help you regain and then improve the use of your hip joint. It's usually possible to return to light activities or office-based work within around 6 weeks. However, everyone recovers differently and it's best to speak to your doctor or physiotherapist about when to return to normal activities. Find out more about recovering from hip replacement surgery. Risks of hip replacement surgery Complications of a hip replacement can include: hip dislocation infection at the site of the surgery injuries to the blood vessels or nerves DVT (deep vein thrombosis) a fracture in the bone around the hip replacement during or after the operation differences in leg length However, the risk of serious complications is low. There's also the risk that an artificial hip joint can wear out earlier than expected or go wrong in some way. Some people may require revision surgery to repair or replace the joint. Find out more about the risks of a hip replacement. Metal-on-metal implants There have been cases of some metal-on-metal (MoM) hip replacements wearing out sooner than expected, causing deterioration in the bone and tissue around the hip. There are also concerns that they could leak traces of metal into the blood. The Medicines and Healthcare Products Regulatory Agency (MHRA) has issued updated guidelines that certain types of MoM devices should be checked every year while the implant is in place. This is so any potential complications can be found early. MoM hip replacements are rarely used now. But if you're concerned about your hip replacement, contact your orthopaedic surgeon. They can give you a record of the type of hip replacement you have and tell you if any follow-up is required. Get more advice about a metal-on-metal implant. The National Joint Registry The National Joint Registry (NJR) collects details of hip replacements done in England, Wales, Northern Ireland and the Isle of Man. Although it's voluntary, it's worth registering. This enables the NJR to monitor hip replacements, so you can be identified if any problems emerge in the future. The registry also gives you the chance to participate in a patient feedback survey. It's confidential, and you have a right under the Data Protection Act to see what details are kept about you. An original NHS Article First published on 14 May 2020

Knee replacement surgery (arthroplasty) is a common operation that involves replacing a damaged, worn or diseased knee with an artificial joint. Adults of any age can be considered for a knee replacement, although most are carried out on people between the ages of 60 and 80. A smaller operation called a partial knee replacement tends to be performed on younger people aged between 55 and 64 where the artificial joint is expected to need redoing within 10 years. When a knee replacement is needed Knee replacement surgery is usually necessary when the knee joint is worn or damaged so that your mobility is reduced and you are in pain even while resting. The most common reason for knee replacement surgery is osteoarthritis. Other health conditions that cause knee damage include: Rheumatoid arthritis Haemophilia Gout Disorders that cause unusual bone growth Death of bone in the knee joint following blood supply problems Knee injury Knee deformity with pain and loss of cartilage Who is offered knee replacement surgery? A knee replacement is a major surgery, so is normally only recommended if other treatments, such as physiotherapy or steroid injections, have not reduced pain or improved mobility. You may be offered knee replacement surgery if: You have severe pain, swelling and stiffness in your knee joint and your mobility is reduced Your knee pain is so severe that it interferes with your quality of life and sleep Everyday tasks, such as shopping or getting out of the bath, are difficult or impossible You're feeling depressed because of the pain and lack of mobility You cannot work or have a social life You'll also need to be well enough to cope with both a major operation and rehabilitation afterwards. Types of knee replacement surgery There are 2 main types of surgery: Total knee replacement – both sides of your knee joint are replaced Partial (half) knee replacement – only 1 side of your joint is replaced in a smaller operation with a shorter hospital stay and recovery period Other surgery options There are other types of surgery which are an alternative to knee replacement, but results are often not as good in the long term. Your doctor will discuss the best treatment option with you. Other types of surgery may include: Arthroscopic washout and debridement – a tiny telescope (arthroscope) is inserted into the knee, which is then washed out with saline to clear any bits of bone or cartilage Osteotomy – the surgeon cuts the shin bone and realigns it so that your weight is no longer carried by the damaged part of the knee Mosaicplasty – a keyhole operation that involves transferring plugs of hard cartilage, together with some underlying bone from another part of your knee, to repair the damaged surface Preparing for knee replacement surgery Before you go into the hospital, find out as much as you can about what's involved in your operation. Your hospital should provide written information or videos. Stay as active as you can. Strengthening the muscles around your knee will aid your recovery. If you can, continue to do gentle exercise, such as walking and swimming, in the weeks and months before your operation. You can be referred to a physiotherapist, who will give you helpful exercises. Read about preparing for surgery, including information on travel arrangements, what to bring with you and attending a pre-operative assessment. Recovering from knee replacement surgery You'll usually be in the hospital for 3 to 5 days, but recovery times can vary. Once you're able to be discharged, your hospital will give you advice about looking after your knee at home. You'll need to use a frame or crutches at first and a physiotherapist will teach you exercises to help strengthen your knee. Most people can stop using walking aids around 6 weeks after surgery, and start driving after 6 to 8 weeks. Full recovery can take up to 2 years as scar tissue heals and your muscles are restored by exercise. A very small amount of people will continue to have some pain after 2 years. Risks of knee replacement surgery. Knee replacement surgery is a common operation and most people do not have complications. However, as with any operation, there are risks as well as benefits. Complications are rare but can include: Stiffness of the knee Infection of the wound Infection of the joint replacement, needing further surgery Unexpected bleeding into the knee joint Ligament, artery or nerve damage in the area around the knee joint Deep vein thrombosis (DVT) Persistent pain in the knee A break in the bone around the knee replacement during or after the operation In some cases, the new knee joint may not be completely stable and further surgery may be needed to correct it. The National Joint Registry. The National Joint Registry (NJR) collects details of knee replacements done in England, Wales, Northern Ireland and the Isle of Man. Although it's voluntary, it's worth registering. This enables the NJR to monitor knee replacements, so you can be identified if any problems emerge in the future. The registry also gives you the chance to participate in a patient feedback survey. It's confidential and you have a right under the Data Protection Act to see what details are kept about you. An original NHS Article First published on 2nd August 2019

Understanding the partial knee replacement alternative to a total knee replacement. The surgery has a great track record for relieving pain and improving function. But it’s a major operation with a relatively long rehabilitation period. Some patients with advanced knee osteoarthritis can get similar results with a faster recovery and other benefits by getting a partial knee replacement. Partial knee replacement isn’t for everyone, there are trade-offs. But for patients who meet the criteria, there are advantages. For example, “patients who get a partial knee replacement are more likely to feel like they have a normal knee,” says orthopaedic surgeon Peter Brooks, MD. Who’s a candidate for a partial knee replacement? Osteoarthritis is caused by deterioration of cartilage in your joints. (Cartilage is the tough material that covers the ends of your bones, providing a smooth gliding surface.) In the knee joint, where the thigh bone (femur) meets the shinbone (tibia), there are three places where bones make contact: On the inside - nearest the opposite knee, referred to as medial. On the outside - farthest from the opposite knee, referred to as lateral. The kneecap - patella. These three points are called compartments. If the arthritis is limited to one compartment, the patient may be a candidate for partial knee replacement. To be eligible, the patient also needs a sufficient range of motion and intact ligaments around the knee. Injury to the anterior cruciate ligament (the ACL, which is in the middle of the knee joint) is common, and it would disqualify the patient from having a partial knee replacement. How does a partial knee replacement work? A partial knee replacement, aka a unicompartmental knee replacement, is similar to total knee replacement, except that the metal and plastic implant that replaces damaged bone and cartilage is placed only on the affected compartment. Most patients with unicompartmental arthritis have it on the medial side. Healthy cartilage, bone and ligaments are left alone. For this reason, most patients report having a more natural-feeling knee. Rehab is quicker and easier than total knee replacement, which takes about three weeks. Because it’s a smaller operation, there’s less pain after surgery and a lower risk for complications. Surgical risks include infection, blood loss, blood clots and injury to a blood vessel or nerve. These are rare, and they’re even less likely with partial than with total knee replacement. Are there any disadvantages to a partial knee replacement? The downside to partial knee replacement is that there’s a higher risk that it will have to be revised in the future to a total knee replacement. There are several reasons for this. Common ones include: Loosening of the implant. Infection. Arthritis developing in the other compartments. Article adapted from Cleveland Clinic Arthritis Advisor First published 10th December 2019

National Institute for Health Research (NIHR) First published on 8 December 2020 doi: 10.3310/alert_42879 - NIHR article A common surgical approach used for hip replacements carries higher risks of worse outcomes and should not be routinely adopted by trainee surgeons, a new analysis suggests. The study found significantly worse outcomes associated with so-called lateral procedures to the hip joint, in which surgeons access the hip by detaching muscle from the side of the thighbone (femur). Lateral procedures were compared with alternative methods in which the surgeon approaches the hip from in front of (anterior approach), or behind (posterior approach), the thighbone. Analysis of 723,904 hip replacement operations performed between 2003 and 2016 found that lateral procedures were associated with more deaths and a greater risk of further hip surgery. The researchers suggest it is probably unwise to ask experienced surgeons to change from using the lateral approach. However, new surgeons should be taught to use other approaches when performing hip replacements. What’s the issue? More than 100,000 hip replacement operations are carried out in the UK each year, and surgeons can access the hip joint using different approaches. The most commonly used is the posterior approach, in which surgeons access the hip from behind the thighbone. Other approaches include accessing the hip from in front of the thighbone (anterior) or, in about one in three operations, surgeons use the lateral approach and reach the hip by detaching muscle from the side of the femur. Each approach can be performed through a small (minimally invasive) cut or a standard, longer cut. The different approaches cause different amounts of soft tissue damage and bleeding. It has been assumed that patients’ recovery, their chances of needing further surgery, and the potential adverse outcomes will be influenced by the approach used. But, before this study, there was little large-scale evidence to assess and compare the outcomes from all of the different surgical approaches. What’s new? The study used data collected by the National Joint Registry to identify 723,904 primary total hip replacements carried out between 2003 and 2016 in England, Wales, Northern Ireland and the Isle of Man. It cross-referenced these data to reports of how the patients fared after surgery. Specifically, it looked at the risk of further (revision) surgery in the long-term, and the risk of death three months after surgery. Data on patient-reported outcomes such as pain, mobility and adverse outcomes six-months after surgery were also reviewed. The study compared these outcomes for each surgical method. Statistical analysis suggested the lateral approach had worse outcomes than the posterior approach. Compared to the posterior approach, the lateral approach: was predicted to have an increased risk (between 5% and 12%) of revision surgery at 12 years was predicted to have a 15% increased risk of death within three months of surgery was associated with only slightly more reports from patients of pain and mobility issues. Overall, the study found that the posterior approach had the lowest risk of revision surgery. Lateral or anterior approaches carried out using minimally-invasive techniques carried an increased risk of further surgery, but the difference was less certain in models accounting for patients' body mass index. The researchers therefore said the data supported the continued use of minimally-invasive techniques at this time. Why is this important? This is the largest study to compare the outcomes from the different ways of performing a common operation. The study was observational and cannot prove that the surgical approach caused the differences in outcomes. However, the data strongly indicate worse outcomes with the lateral approach. It was associated with more deaths and a greater risk of revision surgery. More than 20,000 hip replacements are performed each year in the UK using the lateral approach, and the study authors argue new surgeons should not routinely use it. A better option, they say, is posterior approach surgery, which is already the most common. At present, NICE guidelines state surgeons can choose a posterior or lateral approach for hip replacement. What’s next? The study authors say their findings parallel those from small studies and should be used to inform clinical practice when NICE and other bodies update guidelines. They suggest that surgeons should be steered away from the lateral approach for hip replacement. The posterior approach should be considered the preferred standard approach, they say, and should be used in training new surgeons. They acknowledge that it might be difficult to safely convert experienced surgeons familiar with the lateral approach to a new approach. Ideally, the findings of this large but observational study would be checked in a randomised controlled trial. Such a trial could compare the possible benefits of the minimally-invasive posterior approach, the conventional anterior approach and the conventional posterior approach. The present study suggests that these approaches may have the best outcomes. - - - You may also be interested to read: The full study: Blom AW, and others. The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. BMC Medicine. 2020;18:242 Study from the same group looking at surgical techniques: Matharu GS, and others. The Effect of Surgical Approach on Outcomes Following Total Hip Arthroplasty Performed for Displaced Intracapsular Hip Fractures An Analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. The Journal of Bone and Joint Surgery. 2020;102:21-28 NICE guidance: Surgical approaches for primary elective hip replacement (NG157) (2020), advises in Section 1.8.1 to consider a posterior or anterolateral approach for primary elective hip replacement - - - Funding: The study was supported by the Healthcare Quality Improvement Partnership, National Joint Registry and the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust. Conflicts of Interest: A number of authors have received grants and fees from relevant organisations and device manufacturers. Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

BJBJS - The Journal of Bone and Joint Surgery VOL 81-A, NO. 7. JULY 1999 begins on page 926 ANALYSIS OF ROUTINE HISTOLOGICAL EVALUATION OF TISSUES REMOVED DURING PRIMARY HIP AND KNEE ARTHROPLASTY TREVOR LAWRENCE, F.R.C.S.(ED) ORTH.†, CHARLOTTESVILLE JOSEPH T. MOSKAL, M.D.‡, ROANOKE DAVID R. DIDUCH, M.S., M.D.†, CHARLOTTESVILLE, VIRGINIA First published in The Journal of Bone & Joint Surgery Investigation performed at the Department of Orthopaedic Surgery. University of Virginia Health Sciences Center. Charlottesville, and Roanoke Memorial Hospital, Roanoke ABSTRACT Background: It has often hern hospital policy to send all resected specimens obtained during a total hip or knee arthroplasty for histological evaluation. This practice is expensive and may be unnecessary. We sought to determine the ability of surgeons to diagnose primary joint conditions correctly, and we attempted to identify any possible risks to the patient resulting from the omission of routine histological evaluation of specimens at the surgeon's discretion. Our objective was to ascertain whether routine histological evaluation could be safely omitted from the protocol for primary hip and knee arthroplasty without compromising the care of the patient. Methods: A total of 1388 consecutive arthroplasties in 1136 patients were identified from a database of primary total hip and knee arthroplasties that were prospectively maintained by the senior one of us. Followup data obtained at a mean of 53 years (range, two to ten years) were available after 92% (1273) of the 1388 arthroplasties. The preoperative diagnosis was determined from the history, findings on clinical examination. and radiographs. The intraoperative diagnosis was determined by gross inspection of joint fluid, articular cartilage, synovial tissue, and the cut surfaces of resected specimens. The combination of the preoperative and intraoperative diagnoses was considered to be the surgeon's clinical diagnosis. All resected specimens were sent for routine histological evaluation, and a pathological diagnosis was made. Attention was given to whether a discrepancy between the surgeon's clinical diagnosis and the pathological diagnosis altered the management of the patient. The original diagnoses were updated with the use of annual radiographs and clinical assessments. The cost of histological examination of specimens obtained at arthroplasty was determined by consultation with hospital administration, accounting. and pathology department personnel. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. Department of Orthopaedic Surgery. University of Virginia Health Sciences Center, Box 159. Charlottesville, Virginia 22908. Roanoke Orthopaedic Center. Box 21369, Roanoke. Virginia 24018-0546. Results: A pathological fracture or an impending fracture was diagnosed preoperatively and confirmed intraoperatively during twelve of the 1388 arthroplasties. Histological analysis demonstrated malignancy in specimens obtained during eleven of these arthroplasties and evidence of a benign rheumatoid geode in the specimen obtained during the twelfth arthroplasty. The preoperative and intraoperative diagnoses made before and during the remaining 1376 arthroplasties were benign conditions, which were confirmed histologically in all patients. No diagnosis changed during the follow-up period. As demonstrated by a comparison with the histological diagnosis, the surgeon's clinical diagnosis of malignancy had a sensitivity of 100percent (95 % confidence interval. 74.0 to 100percent), a specificity of 99.9 % (95 % confidence interval. 99.6 to 100 %), a positive predictive value of 91.7 % (95 % confidence interval. 64.6 to 983 %), and a negative predictive value of 100 % (95 % confidence interval.99.7 to 100 %). There was a discrepancy between the preoperative and intraoperative diagnoses associated with eleven ararthroplasties. All eleven intraoperative diagnoses were correct, as confirmed histologically. Excluding the patients who had a pathological or impending fracture, the accuracy of the surgeon's preoperative diagnosis was 992 % (95 % confidence interval. 98.6to 993 %). When the intraoperative and preoperative diagnoses were combined, the accuracy was 100percent (95 % confidence interval. 99.7 to 100percent). Histological evaluation at our hospital resulted in total charges, including hospital costs and professional fees, of $19627 and a mean total reimbursement of $10239 per evaluation. In our series of 1136 patients with 1388 arthroplasties, these costs could have been eliminated for all but the twelve patients who had a suspected malignant lesion and the one patient in whom pigmented villonodular synovitis was found. Conclusions: Benign conditions can be diagnosed accurately by an experienced surgeon. The preoperative diagnosis should be determined on the basis of a carefully obtained history; a detailed physical examination. and a thorough evaluation of radiographs. To complete the clinical diagnosis, the preoperative in­ formation should he combined with findings obtained through careful intraoperative observation of resected specimens and. in the case of hip arthroplasty, an inspection of the divided femoral head. In so doing, the surgeon can usually exclude clinically the possibility of malignancy or another condition that may alter the management of the patient and thus can reserve histological analysis for situations where the diagnosis is suspect or unexpected findings are noted intraoperatively. Illis selective, surgeon-directed use of histological analysis can result in notable financial savings. Escalating charges and declining reimbursements for total knee and hip arthroplasties have led to increasing demands for cost containment. Suggested measures for reducing costs have included decreasing the duration of the hospital slay*2’, standardization of prostheses and suppliers***, increasing the volume of procedures and establishing critical pathways*. However, these practices have been implemented in many hospitals and a plateau for savings may have been reached4. Charges for hospital services such as radiography and laboratory investigations account for about 4% of total costs1'. Many believe that the use of these services at the discretion of the clinician can result in notable savings without compromising patient outcomes (25,22,23,26). During the course of primary hip and knee arthroplasties, the femoral head or resected specimens from the knee are often sent routinely for histological evaluation. This practice may be in concordance with hospital bylaws or a result of the surgeon’s preference. DiCarlo el al. reported that, in a series of 1794 total hip arthroplasties, the rate of discrepancy between the clinical diagnosis and the histological diagnosis based on analysis of the resected femoral head was 5.4% (ninety-seven arthroplasties)’. Because morbid conditions were identified in seven patients, mandatory pathological evaluation of all resected specimens was advocated. However, recent evidence suggests that the surgeon can use his or her discretion in determining which specimens require a histological evaluation and that observed discrepancies between the preoperative and histological diagnoses have little bearing on patient outcome7**. It appears that selective use of histological examination of resected specimens could result in substantial savings. However, to our knowledge, guidelines for adequate clinical evaluation and the possible long-term risks to patients associated with the omission of routine histological evaluation remain to be established. The objective of the present study was to determine whether routine histological evaluation could be safely omitted from the protocol for primary hip or knee arthroplasty without compromising the care of the patient. The surgeon's preoperative and intraoperative diagnoses were compared with the histological diagnosis, and statistical relationships were established. Any change in diagnosis during the follow-up period was noted. Potential economic savings resulting from discretionary use of histological evaluation were also calculated. Materials and Method Between December 1987 and December 1995, the senior one of us (J. T. M.) performed 1388 consecutive primary total hip and knee arthroplasties in 1136 patients, and this group constituted the study population. All demographic and diagnostic data were recorded prospectively in a database. The group included 562 hips and 826 knees Three hundred and eighty-five of the patients were men. and 751 were women. The mean age at the time of the operation was sixty-nine years (range, twenty-two to 100 years). Preoperatively, a complete history was recorded for all patients and all patients were examined clinically and radiographically by the senior one of us who looked for evidence of trauma, tumour, infection, osteoarthritis (primary or secondary), inflammatory arthropathy (rheumatoid arthritis juvenile rheumatoid arthritis systemic lupus erythematosus spondyloarthropathies or crystalline arthropathies), or hemorrhagic arthropathy. Before all of the hip replacements, anteroposterior radiographs of the pelvis and the proximal part of the femoral shaft, as well as lateral radiographs of the involved hip joint, were made with the patient supine. Before the knee replacements, anteroposterior radiographs were made with the patient standing and lateral and Merchant patellar radiographs were made with the patient supine. Some radiographic features were characteristic of a particular diagnosis. For example, meniscal calcifications were seen in association with chondrocalcinosis; increased bone density and collapse, with avascular necrosis; sacroiliac joint fusions with ankylosing spondylitis; and erosive changes with inflammatory arthropathies12*. These findings were combined with information from other treating physicians to establish a preoperative diagnosis for the underlying joint abnormality, and this diagnosis was prospectively recorded in the database. Al the lime of the operation, the senior one of us inspected the joint fluid, the articular cartilage, and the synovial tissue for gross changes characteristic of the preoperative diagnosis In the total hip arthroplasties each femoral head was divided in half and viewed Intraoperatively for areas of collapse, cystic changes or abnormal architecture. Combining these observations al operation with the preoperative diagnosis allowed the determination of an intraoperative diagnosis which also was recorded prospectively. All specimens were then sent for histological evaluation, as required by the hospital bylaws and a pathological diagnosis was made. Preoperative, intraoperative, and histological diagnoses were made for all 1388 hips and knees treated with arthroplasty. The diagnoses were then reappraised al yearly follow-up intervals on the basis of an updated medical history, physical examination, and radiographs. Clinical evaluation included an assessment of joint pain and function with the use of the Knee Society1* or 11 arris14 hip-scoring system. Any change in medical history was noted. Anteroposterior radiographs of the pelvis and the proximal part of the femur and a true lateral radiograph of the hip were made with the patient supine al the follow-up evaluations after the hip replacements. Anteroposterior radiographs were made with the patient standing and lateral and Merchant patellar radiographs were made with the patient supine al the evaluations after the knee replacements. The prosthetic components were evaluated according to previously described radiographic crileriaMJ04UW\ Zonal analysis was used to determine the location, size, and any progression of radiolucent lines and osteolysis. Any changes in diagnosis during the follow-up period were recorded in the database. The surgeon’s diagnosis of underlying malignancy based on preoperative and intraoperative findings was compared with the pathologist's histological diagnosis for every specimen. The results were expressed in terms of sensitivity (the number of malignant lesions that were correctly diagnosed as malignant by the surgeon divided by the total number of malignant lesions identified histologically), specificity (the number of benign conditions that were correctly diagnosed as benign by the surgeon divided by the total number of benign conditions identified histologically), the positive predictive value (the number of malignant lesions that were correctly diagnosed as malignant by the surgeon divided by the total number of malignant lesions that were diagnosed by the surgeon), and the negative predictive value (the number of benign conditions that were correctly diagnosed as benign by the surgeon divided by the total number of benign conditions that were diagnosed by the surgeon). The accuracy of the surgeon's preoperative diagnoses of benign conditions was also calculated in relation to the histological diagnoses (the number of correct diagnoses that were made by the surgeon divided by the total number of the same diagnoses that were made on the basis of the histological evaluation). The overall accuracy of the surgeon’s diagnoses based on both preoperative and intraoperative findings was also calculated. 95 % confidence intervals were determined for all binomial proportions with the use of Wilson’s method. Three patients died perioperatively; one each died from cardiac failure (no autopsy), pulmonary embolism (confirmed at autopsy), and myocardial infarction (confirmed at autopsy). An additional sixty-four patients (seventy-five arthroplasties) died during the follow-up period from causes unrelated to the index operation. Twenty-nine patients (thirty-seven arthroplasties) were lost to follow-up, although none were lost fewer than six months postoperatively. Thus, data obtained al a minimum of two years (range, two to ten years; mean.5.5 years) were available for 1273 (92 %) of the 1388 arthroplasties. The pathology department provided details of professional charges and reimbursements, received according to various insurance options, that were incurred for the gross and histological evaluation of the specimens. Hospital costs associated with histological analysis were calculated after consultation with hospital administration and accounting personnel. The hospital costs included those for slides, reagents and stain preparation, decalcification solutions, equipment (including depreciation), labour, and indirect expenses. Result* The surgeon’s clinical diagnosis (based on the preoperative history, clinical examination, and radiographic findings combined with the intraoperative observations) was most commonly primary osteoarthritis (949 arthroplasties), avascular necrosis (112). rheumatoid arthritis (ninety-two), traumatic arthritis (eighty-two), or acute fracture (eighty-three). The other diagnoses included congenital dislocation of the hip (sixteen arthroplasties), pathological fracture or impending fracture (twelve), ankylosing spondylitis (nine), slipped capital epiphysis (nine), Legg-Calvé-Perthes disease (six), gout (five), chondrocalcinosis (three), Pagel disease (three), a reversal of an arthrodesis (two), juvenile rheumatoid arthritis (two), pigmented villonodular synovitis (one), Gaucher disease (one), and ochronosis (one). A pathological fracture or an impending fracture secondary to an underlying malignant lesion was diagnosed before twelve (1 %) of the 1388 arthroplasties. Intraoperative findings confirmed the preoperative diagnosis but did not yield additional information regarding the pathological condition. The histological diagnoses associated with the twelve pathological or impending fractures included metastatic carcinoma from the breast (four), lung (two), prostate (one), and kidney (one) as well as multiple myeloma (three). One patient in whom a malignant lesion had been suspected on the basis of the preoperative and intraoperative findings had a benign rheumatoid geode. The histological reports were essential to establish the underlying diagnosis in these twelve patients. No occult malignancy was detectedtopologically in the remaining 1376 specimens. The ability of the surgeon to identify malignancy correctly was determined by comparing the preoperative and intraoperative clinical diagnoses of malignancy with the histological diagnoses. This analysis yielded a sensitivity of 100 % (eleven of eleven), with a 95 % confidence interval of 74.0 to 100 %; specificity of 99.9 % (1376 of 1377), with a 95 percent confidence interval of 99.6 to 100 %; a positive predictive value of 91.7 % (eleven of twelve), with a 95 % confidence interval of 64.6 to 98.5 %; and a negative predictive value of 100 % (1376 of 1376), with a 95 % confidence interval of 99.7 to 100%. Since no additional periprosthetic tumours developed during the study period, these values remained unchanged al the latest follow-up evaluation (al a mean of 55 years (range, two to ten years)). ROUTINE HISTOLOGICAL EVALUATION OE TISSUES REMOVED DURING HIP AND KNEE ARTHROPLASTY Charges and Actual Reimbursement Per Payor Class, for Histological Evaluation of Specimens Resected During Total Hip or Knee Arthroplasty Roanoke Memorial Hospital During 1998 The preoperative diagnosis was a benign joint condition before 1376 of the arthroplasties. Eleven preoperative diagnoses, all of the primary osteoarthritis, differed from the intraoperative diagnoses. The revised intraoperative diagnosis was avascular necrosis (grade 3 or 4, according to the system of Ficat el al. (12)) during nine arthroplasties. This avascular necrosis, which was identified after the femoral head was divided, had not been seen on the preoperative radiographs because of the advanced degenerative changes. Ochronosis was diagnosed during one arthroplasty, on the basis of black staining of the synovial tissue, and pigmented villonodular synovitis was diagnosed during the eleventh arthroplasty, on the basis of the characteristic brown pigmentation in hyperproliferative synovial tissue. All of these revised intraoperative diagnoses were the same as the subsequent histological diagnoses. The accuracy of the surgeon’s preoperative diagnosis compared with the histological diagnosis was 99.2 % (1365 of 1376), with a 95 % confidence interval of 98.6 to 99.5 %. The accuracy of the surgeon's combined preoperative and intraoperative diagnoses compared with the histological diagnosis was 100 % (1376 of 1376), with a 95 % confidence interval of 99.7 to 100 %. No diagnoses were revised during the study period (mean duration, 55 years); therefore, the rate of accuracy remained unchanged after more than two years of follow-up. During the follow-up period, an infection developed in eleven patients (eleven arthroplasties), resulting in a two-stage revision in ten of them and a resection arthroplasty in one. Nineteen patients (nineteen arthroplasties) had a revision of one or more components because of aseptic loosening, osteolysis, polyethene wear, or periprosthetic fracture. Eight patients (eight arthroplasties) had an additional operation, without revision of components, because of periprosthetic fracture, instability, or rupture of the extensor mechanism. The findings al the subsequent operation did not alter the final diagnosis for any patient. Radiographs made al the lime of follow-up after the unrevised arthroplasties were analyzed for zonal interface radiolucency^!<ulJ5. Nonprogressive radiolucent lines of no more than two millimetres in width were present in 12% (eighty-eight) of the 727 knees; the lines were seen in thirty-four femora, fifty-one tibiae, and three patellae. No radiolucent lines were complete, and no unrevised components were loose radiographycally1’. Radiographic analysis al the lime of follow-up after the hip arthroplasties revealed that six porous-coated femoral stems had a circumferential radiolucent line or evidence of subsidence10. In addition, three cemented femoral stems had radiolucent lines that were consistent with possible loosening and two had radiolucent lines that were consistent with probable loosening, according to the criteria of Harris and McGann \ A non-progressive radiolucent line was seen in zone 1 adjacent to 7% (thirty-six) of the 516 acetabular cups, in zone 2 adjacent to 24% (124) of the cups, and in zone 3 adjacent to 48% (248) of the cups*. An area of acetabular osteolysis developed in one patient, but it remained asymptomatic al ten years and the patient declined additional operative intervention. At our private, university-affiliated hospital, the total charge per histological specimen analyzed after a total hip or knee arthroplasty in 1998 was $196.27. This includes $152.00 for the pathologist’s professional fees for gross inspection of the specimen and interpretation of the slides. The remaining $44.27 represents direct and indirect costs for decalcification and preparation of the specimen. These costs include those for labour, supplies, and administrative charges. During the same period, actual reimbursement, which was dependent on the type of health insurance (Table I), averaged $16.92 for preparation of the specimen and $85.67 for gross inspection and histological evaluation (a total of $10259) .A malignant lesion was diagnosed before or during twelve arthroplasties, and pigmented villonodular synovitis was diagnosed during one. Histological analysis could have been omitted from the protocols for the remaining 1375 arthroplasties without compromising the outcome or prognosis in the long term. If a discretionary policy for histological evaluation had been implemented, total charges would have been reduced by $269,871.25 and total reimbursements would have been reduced by $141,061.25. DISCUSSION There is increasing evidence that histological evaluation of specimens resected during primary hip and knee arthroplasties should not be mandatory. However, discrepancies between the surgeon’s preoperative diagnosis and the histological diagnosis have been reported after 0.4% (eight) of 2035 total knee arthroplasties24 and after 5.4% (ninety-seven) of 1794 total hip arthroplasties(9). In a series including both hip and knee arthroplasties, in which the protocol was similar to our own, the discrepancy rale was 0.84 percent (six of 715)7, which is comparable with our rate of 0.80% (eleven of 1376). A discrepancy rate of 10% (sixteen of 168) in a series of total hip and knee arthroplasties was reported by Raab cl al.25. However, in that series, pathology requisition forms contained clinical data on only 60% (101) of the 168 hips and knees and little attention was given to intraoperative findings. Unlike the authors of the other studies, we also documented the surgeon’s intraoperative diagnosis. Additional diagnostic information can be obtained by careful inspection of the joint surfaces; synovial tissue; and, when a hip replacement is performed, the cut surfaces of the divided femoral head. In our series, this practice reduced the rate of discrepancy between the surgeon’s combined preoperative and intraoperative diagnoses and the histological diagnosis to zero for benign etiologies. We noted eleven discrepancies between the preoperative diagnosis and the intraoperative diagnosis for patients who had benign conditions. In nine instances, a preoperative diagnosis of primary osteoarthritis was revised to an intraoperative diagnosis of avascular necrosis on the basis of the gross appearance of the cut surfaces of the femoral head. Ochronosis was evident because of the black appearance of the synovial tissue, which is characteristic of this condition. Pigmented villonodular synovitis was similarly diagnosed on the basis of the characteristic appearance of proliferating pigmented synovial tissue. All of the surgeon’s intraoperative diagnoses were confirmed by the histological evaluations. No morbid conditions would therefore have been misdiagnosed had the surgeon decided which specimens were to be sent for histological evaluation. The clinical relevance of discrepancies between the surgeon’s diagnosis and the histological diagnosis has not been fully established. The situation is further complicated by an 8% intraobserver variance (fourteen of 168) in the histological evaluation of resected specimens by pathologists3. This variance raises the question of whether the histological diagnosis is an appropriate so-called gold standard for the final diagnosis. DiCarlo cl al. reported that two of 1794 resected femoral heads had evidence of a malignant condition that had not been suspected preoperatively’. The postoperative management of the two patients was affected by the histological diagnosis. The overall prevalence of this potential disaster is unknown but appears to be very low. In total hip arthroplasties, division and inspection of the femoral head intraoperatively may further reduce the risk of such a missed diagnosis. We are not aware of any other reported series in which a discrepancy between the clinical and histological diagnoses affected the management of the patient. In the present study, at a mean of 5.5 years after the arthroplasty, no diagnosis was revised, the management of the patients was not altered by discrepant histological diagnoses, and no occult periprosthetic malignant lesions developed. Our indications for histological evaluation during primary total hip and knee arthroplasty include a preoperative or intraoperative suspicion of malignancy, pathological fracture, impending pathological fracture, or the need to identify a pathological entity. If those criteria had been used in the present study, a histological evaluation would have been necessary after only 1 percent (thirteen) of the 1388 arthroplasties. Important underlying pathological conditions would not have been missed in any of the remaining patients had histological evaluation been omitted, and the outcome of the operation would not have been compromised. Another potential indication for histological evaluation may be for instructional purposes, including clinical correlation with interpretations of radiographs, in a teaching hospital. In conclusion, our findings support the contention that analysis of histological specimens can be safely omitted from the protocols of most total hip and knee replacements without fear of compromising the outcome and with considerable savings in both hospital charges and costs. It is possible that other studies involving more patients and longer follow-up may lead to different conclusions. Histological evaluation should be omitted only when the surgeon has diagnosed a benign condition on the basis of a carefully obtained history, a carefully performed physical examination, and a thorough review of the radiographs and when the preoperative diagnosis has been confirmed by intraoperative inspection of the resected specimens and, in cases of total hip arthroplasty, the cut surfaces of the femoral head. We advise caution, and we recommend that histological analysis be performed when there is any doubt about the diagnosis or when additional assistance is needed in order to identify the underlying pathological condition. Journal: The Journal of Bone & Joint Surgery Section: Article Published: July 1999; 81 (7): 926 The article was first published on July 1999. Copyright & License Copyright © 1999 by The Journal of Bone and Joint Surgery, Incorporated. Authors: TREVOR LAWRENCE, F.R.C.S.(ED) ORTH.†, CHARLOTTESVILLE JOSEPH T. MOSKAL, M.D.‡, ROANOKE DAVID R. DIDUCH, M.S., M.D.†, CHARLOTTESVILLE, VIRGINIA Department of Orthopaedic Surgery, University of Virginia Health Sciences Center, Box 159, Charlottesville, Virginia 22908. Roanoke Orthopaedic Center, Box 21369, Roanoke, Virginia 24018-0546. REFERENCES 1. Agresti, A„ and Coull, B. Aj Approximate is better than “exact" for interval estimation of binomial proportions. Am. Statistician, 52:119-126.1998. 2. Anglen. Ju Marbcrry, Ku and Gehrke, J,: The clinical utility of duplicate readings for musculoskeletal radiographs Orthopedics, 20:1015-1019.1997. 3. Barber. T. C. and Healy. W. L,: The hospital cost of total hip arthroplasty. A comparison between 1981 and 1990. J. Bone and Joint Surg..75-A: 321-325. March 1993 4. Boardman. I). Lu Lieberman. J. R,: and Thomas. B. J,: Impact of declining reimbursement and rising hospital costs on the feasibility of total hip arthroplasty. J. Arthroplasty. 12: 526-534.1997. 5. Boutin. P., and Hogshead. H,: Surgical pathology of the intervertebral disc Is routine examination necessary? Spine, 17: 1236-1238. 1992. 6. Brooker. A. Fu Bowerman. X W4 Robinson. R. A,: and Riley. L. H,: Ectopic ossification following total hip replacement. Incidence and a method of classification. J. Bone and Joint Surg.. 55-A: 1629-1632, Dec 1973. 7. Campbell. M. Lu Gregory, A. M,: and Mauerhan. I). R,: Collection of surgical specimens in total joint arthroplasty. Is routine pathology cost effective? J. Arthroplasty. 12:60-63.1997. 8. DeLee, J. (L, and Chamlcy. J,: Radiological demarcation of cemented sockets in total hip replacement. Clin. Orthop., 121:20-32,1976. 9. IhCario, E. Fu Bullough. P. Gu Steiner. G,: Bansal. M.: and Kambolis, C,: Pathological examination of the femoral head (abstract). Mod.Pathol., 7:6A. 1994. 10. Engh. C. Au Massin. P.; and Sathers, K. E,:: Roentgcnographic assessment of the biologic fixation of porous-surfaced femoral components. Clin. Orthop.. 257:107-128,1990. 11. Ewald. F. C,: The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin. Orthop.. 248:9-12.1989. 12. Ficat R. Pu Ariel. Ju and Hungerford. D. S,: Necrosis of the femoral head. In Ischemia and Necroses of Bone, pp. 53-74. Edited by R. PFicat. J. Ariel, and D. S. Hungerford. Baltimore. Williams and Wilkins. 1980. 13. Gruen, T. Au McNeice. G. M,: and Amstutz. H. C,: “Modes of failure" of cemented stem-type femoral components. A radiographic analysis of loosening. Clin. Orthop., 141:17-27,1979. 14. Harris. W. H,: Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J. Bone and Joint Surg.. 51-A: 737-755. June 1969. 15. Harris. W. IL. and McGann. W. A,: Loosening of the femoral component after use of the medullary-plug cementing technique. Followup note with a minimum five-year follow-up. J. Bone and Joint Surg.. 68-A: 1064-1066, Sept. 1986. 16. Healy. W. L,: Economic considerations in total hip arthroplasty and implant standardization. Clin. Orthop.. 311:102-108.1995. 17. Healy. W. Lu Iorio, Ru and Richards, X A,: Opportunities for control of hospital cost for total knee arthroplasty. Clin. Orthop.. 345:140-147,1997. 18. InsaU, X Nu Dorr. L. D,: Scott. R. D,: and Scott. W. Nu Rationale of the Knee Society clinical rating system. Clm. Orthop., 248:13-14.1989. 19. Lavernia, C. JL, and Guzman. J. F,: Relationship of surgical volume to short-term mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty. 10: 133-140.1995. 20. Levine, D. Bu Cole. B. J,: and Rodeo. S. A,: Cost awareness and cost containment at the Hospital for Special Surgery. Strategics and total hip replacement cost centers. Clm. Orthop.. 311:117-124.1995. 21. Meyers. S. Ju Reuben, J. D,: Cox. D. D,: and Watson. M,: Inpatient cost of primary total joint arthroplasty. J. Arthroplasty. 11: 281-285’ 1996. 22. Moskal. J. T., and Diduch. D. R,: Postoperative radiographs after total knee arthroplasty. A cost containment strategy. Am. J. Knee Surg.,11:89 93.1998. 23. Nayak. K. N. K,: Rorabcck. C. Hu Bourne. R. B,: Mulliken. Bu and Robinson. E,: Interpretation by radiologists of orthopedic total joint radiographs: Is it necessary or cost-effective? Canadian J. Surg., 39: 393-396.1996. 24. Pag nano, M. W4 Forcro, J. Hu Scuderi. G. R,: and Harwin. S. F,: Is the routine pathological examination of surgical specimens worthwhile in primary total knee arthroplasty? Orthop Trans., 22:139-140.1998-1999. 25. Raab, S. S4 SlagcL D. Du and Robinson. R. A,: The utility of histological examination of tissue removed during elective joint replacement. A preliminary assessment J. Bone and Joint Surg., 80-A: 331-335. March ’.998. 26. Sommers. L. Su Schurman. D. J,: Jamison. X Q,: Woolson. S. T,: Robison. B. L,: and Silverman. X F,: Clinician-directed hospital cost management for total hip arthroplasty patients. Clin. Orthop.. 258:168-175,1990. 27. Steinberg. M. E,: Hay ken. G. D,: and Steinberg, D. R,: A new method for evaluation and staging of avascular necrosis of the femoral head. In Bone Circulation, pp. 398-403. Edited by J. Ariel, R. P. Ficat, and D. & Hungerford. Baltimore. Williams and Wilkins, 1984. 28. Waddell. J. P-, and Morton. J,: Generic total hip arthroplasty. Clm. Orthop.. 311:109-116.1995. This text has been extracted from a printed copy. Whilst every effort has been taken to accurately OCR the original paper, please see attached pdf of the original document for further reference.

THE JOURNAL OF HAND SURGERY VOL. 20B No. 4 AUGUST 1995 T. LAWRENCE, P MOBBS, Y. FORTEMS and J. K. STANLEY From the Hand and Upper Limb Centre. Wrightington Hospital, Wigan, UK Radial tunnel syndrome results from compression of the radial nerve by the free edge of the supinator muscle or closely related structures in the vicinity of the elbow joint. Despite numerous reports on the surgical management of this disorder, it remains largely unrecognised and often neglected. The symptoms of radial tunnel syndrome can resemble those of tennis elbow, chronic wrist pain or tenosynovitis. Reliable objective criteria are not available to differentiate between these pathologies. These difficulties arc discussed in relation to 29 patients who underwent 30 primary explorations and proximal decompressions of the radial nerve. Excellent or good results were obtained in 70%, fair results in 13% and poor results in 17% of patients. The results can be satisfactory despite the prolonged duration of symptoms. We believe that a diagnosis of radial tunnel syndrome should always be born in mind when dealing with patients with forearm and wrist pain that has not responded to more conventional treatment. Patients with occupations requiring repetitive manual tasks seem to be particularly at risk of developing radial tunnel syndrome and it is also interesting to note that 66% of patients with on-going medico-legal claims had successful outcomes following surgery. Journal of Hand Surgery (British and European Volume. 1995) JOB 4: 454-459 ---------------------------- The radial nerve contains a combination of motor, cutaneous sensory, proprioceptive and autonomic fibres (Lluch and Beasley, 1989; Sprofkin. 1954). The precise site of nerve compression and the nature and distribution of the involved axons determines the symptoms associ­ated with radial tunnel syndrome These include pain in (he lateral extensor muscles with repeated pronation and supination, pain and sensory disturbance in the distribution of the superficial branch of the radial nerve, or diffuse wrist pain. There are three pathognomonic signs Intense tenderness is located over the radial nerve at the site of compression and pain may be induced by resisted extension of the middle finger and by resisted supination (Lister et al. 1979; Roles and Maudsley. 1972; Werner. 1979). The anatomy of the radial tunnel and radial nerve has been extensively studied (Abrams et al. 1992; Fuss and Wurzl. 1991; Henry . 1957; Prasartritha et al. 1993: Roles and Maudsley. 1972: Spinner. 1968; Wilhelm. 1958) and is illustrated in Figure 1. The structures implicated in radial tunnel syndrome are shown in Table I. Sites of radial nene compression outside the radial tunnel include the fibrous arch of the long head of triceps (Lotem et al. 1971) and (he lateral head of triceps (Nakamichi and Tachibana. 1991). which should be considered in cases of atypical radial tunnel syndrome. The results from surgical decompression of the radial nerve are generally satisfactory'. There are few reports however on the natural history of this condition. Kaplan (1984) found that after 5 years. 12 out of 15 patients with radial tunnel syndrome treated conservatively had complete resolution of their symptoms. Others, however, have noted the failure of conservative treatment after 9 months, then proceeded to surgery with encouraging outcomes (Moss and Switzer. 1983 ). The precise role of surgery remains to be established. The operation The extent of the radial nerve release is decided pre-operatively based on the symptoms of the patient and the site of maximal tenderness. Symptoms referred to the dorsal and radial aspects of the wrist arc probably due to irritation of (he superficial branch of the radial nerve (SBRN). Since this nerve always passes super­ficial to the arcade of Frohse. we can conclude that the site of irritation in these patients is proximal to the arcade where both the SBRN and the posterior inteross­eous nerves can be involved. It is therefore imperative to extend the release of the radial nerve proximal to the arcade of Frohsc and divide fascial bands when there are symptoms suggestive of SBRN involvement. We also believe that the proximal limit of the release should incorporate the site of maximum tenderness. Al present, it is impossible to correlate precisely the pre­ operative site of maximal tenderness with the structures found intra-operatively It is, therefore, prudent to extend the release of the radial nerve proximal to the arcade of Frohsc when dense fascial bands arc seen, especially when symptoms in the distribution of the SBRN pre­ dominate. For these reasons, we now prefer an extended anterior approach (Green. 1793) to (he radial tunnel allowing safe access proximal io the arcade of Frohse. Several other operations have also been described as a limited anterior exposure of supinator (Henry. 1957). transbrachioradialis approach (Roles and Maudsley. 1972) and a lateral approach (Capener. 1966). Extended anterior exposure (Green. 1993) A "lazy S” incision is made across the elbow joint lateral to biceps tendon The radial nerve is identified proximally between extensor carpi radialis longus and brachialis and followed distally to the Arcade of Frohsc. It is important to establish the anatomy and identify the radial nerve and its superficial branch. The arm is pronated and supinated to demonstrate the constricting structures and these are divided. The minimum inter­vention is a division of the fibrous arcade of Frohse. Exposure and release of the radial nerve from encasing proximal fascia can be undertaken with greatest cer­tainty and safety using the extended anterior approach the drawback of this technique is the long scar across the elbow but m our experience. this is rarely a practical problem except occasionally in young women who are concerned about cosmetic appearance before the scar lades. PATIENTS AND METHODS Between 1978 and 1993. 33 patients were identified who had undergone primary exploration of the radial tunnel Wrightington Hospital One patient underwent bilateral radial tunnel release. 29 patients who had a total of 30 primary operations were reviewed either al pre­ arranged clinics or in their homes. Four patients were lost to follow-up. The medical records of the patients under review were scrutinised and the patients were examined by questionnaire, visual analogue scales and lamination. Grip and pinch strengths were recorded, and the incisions were assessed for tethering, tenderness and cosmetic appearance. In the group of patients with poor results, an attempt was made to establish the factors contributing to an unsatisfactory outcome. 16 were female and 13 male, with a mean age of 415 years (range 16 69). Follow-up from the time of surgery- ranged from I year to 10 years with a mean of 4 5 years. There were 12 tertiary referrals Delay in diagnosis prior to surgery ranged from 0 to 10 years (mean 3 years). Six patients had ongoing medico-legal claims The oper­ated limbs were dominant in 26 cases and non-dominant in four. The right arm was operated on in 26 patients and the left in four. Nerve conduction studies were undertaken in 19 patients and were positive in only six. Clinical presentation A wide variety of symptoms were found in this group of patients (Table 2). Pain m the region of the arcade of Frohse was the commonest, often in association with writer’s cramp I Department of Social Security Prescribed Disease A4). In our scries, writer’s cramp was defined as proximal forearm pain associated with writing, severe enough to prevent prolonged activity; the alternative definition of focal dystonia with bizarre postures was not seen. All patients had tenderness localised over the radial nerve, distinct from the lateral epicondyle thereby differentiating the condition from chronic tennis elbow Tenderness over the radial nerve in the flexor compartment is a common finding and it is therefore important to compare the seventy with the unaffected limb Three patients presented with a palsy of the posterior interosseous nene. Patients describe the pain in the vicinity of ligament of Frohse as "constant aching” aggravated by or pre­venting activity. The distal symptoms in the region of the wrist or dorso-radial aspect of the forearm are poorly localised and consist of paraesthetic or burning sensations sometimes associated with painful finger or venous swelling. Table 2: Distribution of symptom associated with radial tunnel syndrome Symptom .Vu Proximal forearm pain near arcade of Frohse 20 Writers cramp* 17 Paraesthesia 12 Weakness of grip 9 Night cramp 7 Proximal radiation of pain into the arm 6 Distal radiation el pain into the hand 8 Pain in the distribution of the SBRS 5 Wrist tightness 3 Finger swelling 3 *See text for definition ---------------------------- Occupation The majority of patients had manual occupations requir­ ing repetitive pronation and supination (Table 3). Previous diagnoses prior to radial tunnel release Prior to the exploration of the radial tunnel, 20 out of 29 patients had received treatment for other suspected conditions (Table 4). Six patients underwent operative release of tennis elbow and three had undergone release of the first extensor compartment (de Quervain's tenovaginitis stenosans) without relief. Operative exposures of the radial nerve The number of patients undergoing full anterior expo­ sure of the radial nerve has increased recently. The exposures employed are summarized in Table 5. Operative findings Structures compressing the radial nerve were identified by pronating and supinating the forearm (Table 6). In some patients, several pathological structures were noted. No patients had evidence of permanent nerve injury, such as fibrosis, swelling or inflammation. Table 3 - Occupations Occupation No Professional student 20 Assembly line workers 3 Heavy' goods fitters carriers 6 Housewife 3 Secretarial VDU operator 3 Labourer 2 Multiple occupations 2 Table 4 - Diagnoses prior to release of radial tunnel Diagnoses No Tennis elbow 16 Tenosynovitis 3 de Quervain's 3 Wartenberg's 3 Ulnar nerve compression 1 Cervical radiculopathy 1 Table 5 - Operative procedures for release of radial nerve Anterior division of the arcade of Frohse only 14 Extended anterior release of radial nerve 13 Retrobrachialis approach to arcade to Frohse 3 Table 6 - Structures compressing the radial nerve Structure No. Tight arcade of Frohse 15 Dense proximal fascial bands 12 Tight superficial component of supinator 10 Compressive vessels 3 Nil of note 5 RESULTS On the basis of visual analogue assessment, our results can be classified as follows: excellent 18 30 (60%). good 3 30 (10%), fair 4 30 (13%), and poor 5 30 (17%). A score of 0 refers to no improvement and 100 corresponds to complete recovery. We consider that scores of 80 to 100 are excellent results. 50 to 79 good. 20 to 49 fair and 19 or less represent poor results. In our series, one patient felt that her symptoms were aggravated by the operation. The results are summarized in Figure 2. Functional outcome Three patients presented with weakness of forearm extensor muscles, two of which made a full recovery and the third failed to improve. Pain was the predomi­nant symptom in 29 out of 30 patients and restricted their activities. At review, 12 out of 29 patients (41%) were completely pain-free with all activities. Nine out of 29 (31%) patients fell that pain restricted only the most strenuous of activities, and eight out of 29 (28%) felt that light activity was restricted. These patients fell into the respective excellent, good, and poor result groups shown above. Objective assessment Two-point discrimination was initially assessed but was abandoned because of inconsistent results. There were no significant differences between operated and non­ operated hands regarding grip and pinch strengths. PARAESTHESIA 12 patients were troubled with paraesthesia pre- operatively. Of these, one (8%) had complete resolution of symptoms, two (17%) had some improvement, and ten (85%) failed to improve significantly. One patient developed paraesthesia after the operation. COMPLICATIONS Three patients developed mild reflex sympathetic dys­ trophy which resolved with physiotherapy and guanethidine block. One patient developed a transient posterior interosseous nerve palsy which resolved after 6 months of conservative treatment. One patient developed a scar contracture following a post-operative infection which was revised using a Z-plasty. Two patients developed hyperaesthesia in the distribution of the superficial radial nerve. The remaining scars were well healed and asymptomatic. ASSESSMENT OF POOR RESULTS Four out of five patients with poor results at review had evidence of additional pathology. These included an avulsion fracture of the lateral epicondyle, a loose body in the elbow joint, severe cervical radiculopathy and a progressive palsy of the radial nerve of unknown aeti­ ology despite extensive neurological investigation (mononeuritis). Three out of four patients with fair results also had evidence of additional pathology. One had ulnar impingement on the TFCC and is awaiting ulnar short­ening, one had advanced first carpometacarpal arthrosis and the third had suspected Wartenberg’s syndrome. Release of the superficial branch of the radial nerve did not improve symptoms. An attempt was made to assess which factors may be of predictive value regarding diagnosis and successful outcome. Only eight out of 14 men (57%) had successful procedures whereas 13 out of 16 (81%) of women were very satisfied with their operations. Five out of six patients with positive nerve conduction tests had good results. All patients with night pain had successful outcomes. Despite the presence of ongoing medico-legal claims, four out of six patients had good or excellent results. DISCUSSION Radial tunnel syndrome has been a recognised clinical entity for over 20 years. Capener (1966) described ten patients who underwent division of the arcade of Frohse because of chronic resistant tennis elbow. The first comprehensive account of this condition was given by Roles and Maudsley (1972). Subsequent series have been reported by Lister et al (1979). Moss and Switzer <1983). Hagert et al (1977). Ritts et al (1987) and Werner (1979). Our study confirms previous reports regarding the diversity of symptoms associated with radial tunnel syndrome (Moss and Switzer, 1983). Pain is the com­monest symptom and is usually located near to the site of compression over supinator. It can also be distributed to the dorsum of the wrist, dorso-radial aspect of the forearm and onto the volar aspect of the thenar emi­nence. This pattern of referred pain corresponds to the distribution of the posterior interosseous nerve to the carpus (Wilhelm. 1958) and to the distribution of the SBRN respectively. The distribution of the latter includes a variable area on the dorsum of the thumb, the carpus and first CM joint. A branch of the SBRN can also supply the skin over the thenar eminence (palmar cutaneous branch of the radial nerve). Paraesthesia is often poorly defined and is often commented upon as a symptom not corresponding to known anatomical or pathological patterns. In our series, the release of the radial tunnel resulted in general improvement in pain, but only three out of 12 patients with paraesthesia were relieved of their symptoms. One patient developed paraesthesia secondary to the oper­ation although the pain improved. It is not currently possible to explain all the symptoms associated with radial tunnel syndrome as it involves the complex interrelationship of cutaneous, propriocep­tive. motor and autonomic innervation. Finger swelling, painful venous dilation, dysaesthesia or allodynia (noxi­ ous sensations generated by non-noxious stimuli applied to normal skin) may be related to autonomic dysfunction as identified by Lluch and Beasley (1989). and Sprofkin (1954). The complexity is further illustrated by the observation that dysaesthesia following injury to the SBRN can be improved by division of the posterior interosseous nerve at the level of the wrist joint (Lluch and Beasley, 1989). The pathophysiology of radial tunnel syndrome remains unclear. There are no rigid bony confines to the radial tunnel as found in carpal tunnel and cubital tunnel syndromes. Werner et al (1980), demonstrated pressures of 40 to 50 mm Hg exerted by a fibrous ligament of Frohse and these pressures rose to 190 mm Hg under tetanic muscle contraction. This is of sufficient magnitude to induce nerve ischaemia and blockade of nerve impulses. In addition, the fibrous ligament of Frohse may directly traumatize the radial nerve resulting in oedema and later fibrosis. Lister et al (1979) saw evidence of narrowing, hyperaemia and pseudoneuroma formation in six cases. Excellent or good results for radial tunnel release range from 51% (Ritts et al. 1987) to 93% (Moss and Switzer. 1983). We found that 70"/,. of patients had good or excellent results. Ritts suggested that their •>oor results could be accounted for by the nature of the tertiary referrals and high incidence of worker's compen­sation at the Mayo clinic. We found that outstanding medico-legal claims did not adversely affect the clinical outcome although our numbers do not permit statistical analysis. We believe that seven out of nine patients with poor results had pathology other than radial tunnel syndrome, highlighting the need for improved patient selection and objective criteria for this disorder. Werner (1979) noted that lateral epicondylar tenderness, a posi­tive middle finger extension test, a muscular arcade of Frohse, and evidence of nerve injury were associated with a poor prognosis. We found that the best prognosis was associated with women and patients with positive nerve conduction tests and night pain. Having arrived at a diagnosis of radial tunnel syn­ drome, it is important to select the correct level for the release of the radial nerve. Pain over the dorsum of the wrist and over supinator is related to compression of the posterior interosseous nerve at the level of the arcade of Frohse. A limited anterior approach with division of the arcade will probably be adequate. If there are also symptoms in the distribution of the SBRN. the site of compression is probably proximal to the arcade of Frohse and therefore a more extensive release is required. For this reason, it is essential to determine the level of maximal tenderness pre-operatively and extend the release to that point. It is equally important to check for tenderness over the lateral head of triceps and at the level where the radial nerve passes through the intramus­cular septum, two additional sites of compression. A comprehensive analysis of the correlation between the site of nerve compression and the associated signs was given by Fuss and Wurzl (1991). We feel that it is unwise to undertake an extensive distal release of the SBRN even when symptoms suggest involvement of this nerve. In our unpublished series of Wartenberg’s disease, release of the SBRN proximal to the wrist was associated with a high incidence of reflex sympathetic dystrophy. A more proximal release of the SBRN may result in similar complications. Wartenberg’s disease (Wartenberg, 1932; Sprofkin 1954) is a monone­ uritis of the superficial branch of the radial nerve resulting from trauma of the nerve in its subcutaneous distribution. Compression can also occur as the SBRN pierces the deep fascia in the region of the tendinous intersection of brachioradialis and extensor carpi radialis longus (Mackinnon and Dellon. 1985). We are looking for ways of improving patient selec­tion. Fair or poor results can be due to incorrect diagnosis, incomplete release or irreversible nerve injury. In this series, four out of the five patients with poor results were probably incorrectly diagnosed. Unfortunately, nerve conduction studies are not sensi­tive or specific for diagnosing radial tunnel syndrome. Positive studies are useful in confirming the diagnosis and excluding cervical radiculopathy but the majority of tests are negative (12 out of 18 in our series) despite symptoms suggestive of significant compression (Ritts et al. 1987; Werner, 1979). Local injection of anaesthetic agents at the site of maximal tenderness has been reported (Ritts et al, 1987). It may be that this in combination with provocation testing will improve diag­nostic accuracy. Table 7—Possible presentations of radial tunnel syndrome • Forearm pain radiating from the elbow to the wrist • Chronic wrist pain with radial sided dysaesthesia • Dorsal, radial, and occasional thenar sited wrist pain associated with swelling • Failed tennis elbow treatment • Failed de Quervain's release • Wartenberg’s neuropathy (handcuff neuritis) • Dorsal ‘tenosynovitis’ without crepitus or thickening • Burning pain in the forearm and hand (autonomic dysfunction) The role of nerve conduction studies (NCS) in the diagnosis of radial tunnel syndrome remains contro­versial. In most series the techniques used for the studies were not described or were incomplete. Ritts (1987) found that only 9% of patients had positive studies. Werner (1979) demonstrated that only 13 out of 25 patients with suspected pathology had electromyo­ graphic evidence of nerve compression but no significant difference was noted in outcomes with respect to the electromyographic findings. In our series, 33% of patients who had undergone NCS had positive results and of those, five out of six had excellent outcomes. Rosen and Werner (1980) demonstrated that static motor nerve conduction at rest was not significantly different in the symptomatic patients compared with an asymptomatic control group. A significant difference however was demonstrated on active weak supination (less than 2 Newtons of force). These findings suggest that radial tunnel syndrome can present at various stages; in the early stages, symptoms are intermittent with variable involvement of motor and sensory compo­nents, and in the later stages nerve damage increases and may eventually become irreversible. The results of nerve conduction studies simply reflect the stage of compression at presentation. We conclude that the diagnosis of radial tunnel syn­drome should be considered in the circumstances given in-Table 7. We also believe that there is a need to develop objective assessment techniques that will more accurately identify patients suffering from radial tunnel syndrome and localise the site of compression. ---------------------------- References ABRAMS. R A.. BROWN. R A. and BOTTE. M J. (1992). The superficial branch of the radial nerve: An anatomic studs with surgical implication* Journal of Hand Surgery. 17A: 6: 1037 1041. CAPENER. N. ( 1966). The vulnerability of the posterior interosseous nerve of the forearm: A case report and an anatomical study Journal of Bone and Joint Surgery. 48B: 4: 770-773. FUSS. F. K. and WURZL. G. II. (1991). Radial nerve entrapment at the elbow. Surgical anatomy. Journal of Hand Surgery. 16A: 4: 742-747. GREEN. D. P Operative Hand Surgery 3rd Edn. Neu York. Churchill Livingstone. 1993. HAGERT. C G.. LUNDBORG. G and H ANSEN. T (1977). Entrapment e the posterior interosseous nerve. Scandinavian Journal of Plastic and Reconstructive Surgery. 11: 205 212. HENRY. A. K. Extensile Exposure. 2nd Edn.. Edinburgh. Livingstone. 195 KAPLAN. P. E. ( 1984). Posterior interosseous neuropathies: Natural history Archives of Physical Medicine and Rehabilitation. 65 399 40H. LISTER. G. D.. BELSOLE. R B and KLEINERT. H. E. (1979). The radial tunnel syndrome. Journal of Hand Surgery. 4: 1: 52-59. LLUCH. A. L. and BEASLEY. R. W. (1989). Treatment of dysesthesia of the sensory branch of the radial nerve by distal posterior interosseous neurec­tomy. Journal of Hand Surgery. 14A: 1: 121-124. LOTEM. M.. FRIED. A.. LEVY. M. et al. (1971). Radial palsy following muscular effort. Journal of Bone and Joint Surgery. 53B: 3: 500-506. MACKINNON. S. E. and DELLON. A. L. (1985). The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. Journal of Hand Surgery. 10A: 4: 522-526. MOSS. S. H. and SWITZER. H. E. ( 1983). Radial tunnel syndrome: A spectrum of clinical presentations. Journal of Hand Surgery. 8: 4: 414-420. NAKAM1CHI, K. and TACHIBANA. S. (1991). Radial nerve entrapment by the lateral head of triceps. Journal of Hand Surgery. 16A: 4: 748-750. PRASARTRITHA. T.. LIUPOLVANISH, P. and ROJANAKIT. A (1993). A study of the posterior interosseous nerve (PIN ) and the radial tunnel in 30 Thai cadavers. Journal of Hand Surgery. 18A: I: 107- 112. RITTS. G. D.. WOOD. M B. and LINSCHEID. R. L. (1987). Radial tunnel syndrome: A ten-year experience. Clinical Orthopaedics and Related Research. 219: 201-205. ROLES. N. C. and MAUDSLEY. R H. (1972). Radial tunnel syndrome: Resistant tennis elbow as a nene entrapment. Journal of Bone and Joint Surgery. 54B; 3: 499-508. ROSEN. 1. and WERNER. C. O. (1980). Neurophysiological investigation of Posterior interosseous nerve entrapment causing lateral elbow pain. Electroencephalography and Clinical Neurophysiology. 50: 125 133 SPINNER. M. (1968). The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. Journal of Bone and Joint Surgery. 50B: 4: 809-812. SPROFKIN. B. E. ( 1954). Cheiralgia paraesthetica: Wartenberg's Disease Neurology. 4: 857-862. WARTENBERG. R. (1932). Cheralgia paraesthetica (lsolierte Neuritis des Ramus superficialis nervi radialis). Zeitschrift fur die Gesante Neurologie und Psychiatrie. 141: 145-155. WERNER. C. O.. HAEFFNER. F. and ROSEN. I (1980). Direct recording of local pressure in the radial tunnel during passive stretch and active con­ traction of the supinator muscle. Archives of Orthopaedic and Traumatic Surgery. 96: 299-301. WERNER, C. O. (1979). Lateral elbow pain and posterior interosseous nerve entrapment. Acta Orthopaedica Scandinavica: Suppl. 174: 1-62. WILHELM. A. (1958). Zur Innervation der gelenke der oberen extremitat. Zeitschrift fur Anatomie und Enlwicklungsgeschichte. 120: 331-371. Accepted: 18 August 1994 MrJ.K. Stanley. Hand and Upper Limb Centre. Wrightington Hospital. Hall Lane. Wigan. UK © 1995 The British Society for Surgery of the Hand This text has been extracted from printed copy. Whilst every effort has been taken to accurately OCR the original paper, please see attached pdf of the original document for further reference.

First published in The Open Orthopaedics Journal, 2014, 8, (Suppl 1: M5) 162-167) HEFT Orthopaedic Directorate Current Concepts in Acute Knee Dislocation: The Missed Diagnosis? A novel technique for extraction of a fractured femoral stem in revision hip arthroplasty. Management of Leg Length Inequality and Foot Drop Following Staged Reconstruction of Pelvic Discontinuity, with Massive Femoral and Acetabular Bone Loss Four-Year Results Following Composite Bone Grafting (CBG) Technique for Primary Total Hip Replacements (THR) with Patient Outcome Scores. I have developed a new technique for Acetabular Impaction Grafting and have an excellent outcome with supportive data collected over 15 years. The potential for research from this data is extensive. I would benefit from some support from the Trust in terms of rationalising my workload and allocation of Junior Grades to assist with the continued research and writing papers based on the work. I have shown examples of recent publications and presentations below. I have numerous ideas for new papers and currently have several papers in the pipeline. Femoral Stem in Revision Hip Arthroplasty has been proposed for E-POSTER presentation at the XXVI SlCOT Triennial World Congress combined with the 48th SHOT Annual Meeting, to be held In Rio de Janeiro, Brazil, from 19 to 22 November 2014. Trevor Lawrence FRCS (Orth) Research 1. Current Concepts in Acute Knee Dislocation: The Missed Diagnosis? Lesley McKee (1), Mazin S. Ibrahim* (1), Trevor Lawrence (1), Ioannis P. Pengas2 and Wasim S. Khan (2). (1) Trauma and Orthopaedic Department. Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital. Bordesley Green East, Birmingham, B9 5SS. UK (2) University College London Institute of Orthopaedics and Musculoskeletal Sciences. Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK. Abstract: Traumatic knee dislocation is a serious and potentially limb threatening injury that can be easily missed if meticulous history and examination have not been employed. Neurovascular injuries are common in this condition, and due diligence should be given to their thorough evaluation at the time of secondary survey so as to avoid complications such as ischaemia, compartment syndrome and eventual amputation. There is growing evidence in the literature that morbid obesity is associated with low energy knee dislocation, therefore this should be considered when assessing this cohort of patients presenting with an acute knee injury. Early operative intervention especially with multi ligaments involvement is the preferable strategy id the management of this acute injury. Controversy exists whether to reconstruct or repair damaged structures, and whether to adopt a one-stage or two-stage reconstruction of the cruciate ligaments. Early rehabilitation is important and essential to achieve satisfactory outcomes. This article is an evidence-based overview of this rare but devastating injury. Keywords: Knee dislocation, knee injuries, knee joint, ligaments, nerve injury, vascular system injuries. INTRODUCTION Traumatic knee dislocation (KD) is a serious and potentially limb threatening injury, albeit a relatively rare condition, the incidence has been reported as approximately 0.02-0.2% of orthopaedic injuries [I-3J. There is some variance on the definition of knee dislocation, though it can be generally considered to include disruption of at least 2 out of 6 of the major ligamentous and cartilaginous structures, with or without instability. These injuries have historically beet ) attributed to high-velocity impacts (HVKD ) however, more recently they are being noted in low-velocity incidents (LVKD ), particularly involving morbidly obese people. There is an associated high risk of neurovascular damage particularly to the popliteal artery and the common peroneal nerve, where they are tethered by the popliteal fossa boundaries and fibular head respectively, reported to be between 20 -40% and as high as 64% for popliteal artery damage in some studies [4, 5J. Knee dislocations (KD) often reduce spontaneously out with the emergency department, potentially leading to a high rate of delayed presentation or missed diagnosis (6, 7]. With regard to the latter, spontaneously reduced dislocations often have normal radiographs and minimal clinical signs: the physician must be vigilant and have a high index of suspicion to avoid missing the diagnosis and its potentially devastating complications. Complications of missed KD can include vascular compromise, ischaemic limb, permanent nerve damage, popliteal vessel thrombosis, acute compartment syndrome requiring decompression fasciotomies and even amputation (1, 5, 6, 8]. EPIDEMIOLOGY The true rate of knee dislocations is not known due to the number of spontaneous dislocations [8]. Knee dislocations arc traditionally divided epidemiologically into those caused by high-velocity trauma such as an R.TA or low-velocity trauma such as those sustained in sporting injuries. KD tends to occur in younger patients and occurs in a male to female ratio of 4: 1 [8], More recently there has been literature reporting the rise of knee dislocations in the morbidly obese [9 -13]. Georgiadis et al. reported an increase in low-velocity knee dislocations in the morbidly obese from 17% between 1995-2000 to 53% in 2007- 2012 (J I]. The same study also found that obese patients with low energy knee dislocations were more likely to have neurovascular injuries requiring surgical intervention than patients with higher energy traumatic dislocations. However, traditionally, low-velocity knee dislocations have lower rates of neurovascular injury [12]. CLASSIFICATIONS Conventionally, the dislocated knee is categorised radiographically m a positional fashion by the displacement of the tibia relative to the femur. This system was originally developed by Kennedy in 1963 [2]. It classifies dislocations into 5 types: Anterior, posterior, medial, lateral or rotatory. Rotatory­ subtypes are divided into anterolateral, anteromedial, posterolateral and posteromedial types. Of these, posterolateral disruptions are the most difficult to reduce [6]. ___________________ * Address correspondence to this author al the Trauma and Orthopaedic Department, Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Bordesley (Green East. Birmingham, 09 5SS. UK; Tel: 07902017594; E-mail: dibrm80@yahoo.com 1874-5250,-14 2014 Bentham Open ___________________ 2. A Novel Technique for Extraction of a Fractured Femoral Stem in Revision Hip Arthroplasty Mas L McKee, BSc, MBChB, MRCS Specialist Registrar, Trauma and Orthopaedic surgery. Heart of England NHS Trust Work: via switch 0121 424 2000 moNte: 07782514182 On Tub, 20 May 2014 11:4138+0100 (BST) "SICOT CONGRESS* wrote: Dear Mr Gurdip CHAHALL, We are pleased to inform you that your abstract , number 37587, entitled : A Novel Technique for Extraction of a Fractured Femoral Stem in Revision Hip Arthroplasty . has been proposed for E-POSTER presentation at the XXVI SlCOT Triennial World Congress combined with the 48th SHOT Annual Meeting, to be held In Rio de Janeiro, Brazil, from 19 to 22 November 2014. The e-posters will be available during the entire Congress via computers in the e-poster area at the SulAm8eacute;rica Convention Centre Only those authors who have received a confirmation of their registration and payment from the SICOT Congress Secretariat by 19 June 2014 will receive a link to upload their e-posler file(s). The links will be sent later on Io all registered authors presenting e-posters. E poster guidelines: 6MB Is the maximum size that can be uploaded. The presentations can be uploaded in odt, ppt, pptx and pdf formats only. Images, tables and detailed data may be used No videos or multimedia may be used. E-poster presentations may include 6 to 10 slides (landscape orientation) with the following information: Slide 1: Abstract number, trite, list of authors and authors' affiliations Slide 2: Introduction to problem Slide 3: Materials and methods (Ind. statistical analysis. If any) Slide 4: Results Slide 5: Discussion (Ind. current literature review) Slide 6: Conclusions / Conflict of Interest declaration IMPORTANT NOTE: The presenting author of an accepted abstract must register and pay the congress registration fee by 19 June 2014 to be included in the Final Programme. The Congress Secretariat will not check if co-authors have registered Abstract submitters can change the presenting author of an abstract through the abstract submission system until 19 June 2014, by clicking on the link in the confirmation email received after submitting the abstract. Please ensure that the family name, given name, institute, and address of the presenting author have been inserted in the system. Registration can be done on the SlCOT website: http://www.sicot.org/?id_page=602. Presenting authors are kindly requested to Insert their abated number(s) on the registration form and to check that their FAMILY name and GIVEN name(s ) have been inserted In the corresponding field and spelt In the same way as on the abstract submission form. For example, if ' Smith* has been Inserted as the Family Name on the abstract submission form, please ensure that *Smith* has also been inserted as the Family Name on the congress registration form. Become a SICOT member and save money on your congress registration fee. Special preferential membership dues are available for new members from the APOA and SLAOT member countries, our Friendship Nations. They will also benefit from the reduced registration fee for SICOT members. Visit the SICOT website, http://www.sicot.org/?id_page=17 to find out how you can join SICOT. If you have any questions, please do not hesitate to contact us at congress@sicot.org. We took forward to seeing you In Rio de Janeiro. Yours sincerely. Joeé Sergio Franco Congress President Keith OK Luk SICOT President-Elect Chairman of the Congress Scientific Advisory Committee ___________________ 3. Management of Leg Length Inequality and Foot Drop Following Staged Reconstruction of Pelvic Discontinuity, with Massive Femoral and Acetabular Bone Loss Heart of England L McKee. G. Chahal, J. McArthur. T. Lawrence ___________________ 4. Four-Year Results Following Composite Bone Grafting (CBG) Technique for Primary Total Hip Replacements (THR) with Patient Outcome Scores. Dear Mr Sheethai prasad PATANGE SLIBBA RAO, We are pleased to inform you that your abstract, number 37696, entitled: Four-Year results following composite bone grafting ( CBG) technique for primary total hip replacements (THR) with patient outcome scores: prospective single centre study ., has been proposed for ORAL presentation at the XXVISCOT Triennial World Congress combined with the 46th SBOT Annual Meeting, to be held In Rio de Janeiro, Brazil, from 19 to 22 November 2014. The allocated presentation time is sot minutes, plus an extra two minutes lor discussion. The scientific programme is subject to change and the final date, time, and session will only be announced after 19 June 2014. Please check the SICOT website for updates. IMPORTANT NOTE: The presenting author of an accepted abstract must register and pay the congress registration fee by 19 June 2014 to be included in the Final Programme. The Congress Secretariat will not check HI co-authors have registered. Abstract submitters can change the presenting author of an abstract through the abstract submission system until 19 June 2014 by clicking on the link in the confirmation email received after submitting the abstract. Please ensure that the family name, given name, Institute, and address of the presenting author have been inserted in the system. Registration can be done on the SICOT website: http://www.sicot.org/?id_page=802. Presenting authors are kindly requested to Insert their abstract number) on the registration form and to check that their FAMILY name and GIVEN names) have been inserted In the corresponding field and spelt in the same way as on the abstract submission form. For example, if 'Smith’ has been Inserted as the Family Name on the abstract submission form, please ensure that ’Smith* has also been Inserted as the Family Name on the congress registration form. Become a SICOT member and save money on your congress registration tee. Special preferential membership dues are available tor new members residing In the APOA (Asia Pacific Orthopaedic Association) and SLAOT (Latin American Society of Orthopaedics and Traumatology) member country, our Friendship Societies They will also benefit from the reduced registration fee for SICOT members. Visit the SICOT website, http://www.sicot.org/?id_page=17, to find out how you can join SCOT. If you have any questions, please do not hesitate to contact us at congress@sicot.org. We look forward to seeing you in Rio de Janeiro. Yours sincerely, José Sergio Franco Congress President Keith DK Luk SICOT President Elect Chairman of the Congress Scientific Advisory Committee This text has been extracted from a printed copy. Whilst every effort has been taken to accurately OCR the original paper, please see attached pdf of the original document for further reference.

First published in Hip International / Vol. 15 no. 3, 2005 / pp. 155-158 © Wichtig Editore, 2005 EARLY FAILURE MODALITIES IN HIP RESURFACING S. CUTTS, A. DATTA, K. AYOUB, H. RAHMAN, T. LAWRENCE Solihull Hospital, Birmingham - UK ABSTRACT: Between 1996 and 2002, we treated 60 patients (65 hips) by hip resurfacing. The notes and radiographs of these cases were studied retrospectively and the modalities of failure identified. At a mean follow-up of 51 months, 14 of these cases (22%) required revision surgery. One patient had died from unrelated causes and one was lost to follow-up. At the time of primary surgery, the mean age of the patients in our series was 55 years. The commonest mechanism of failure in our series was fractured neck of femur (six cases). Four of these occurred in females over the age of 60. None of the fractured necks of femur were associated with trauma. There were four cases of loose acetabular components and one case of progressive AVN (avascular necrosis). Two patients required revision surgery for ongoing hip pain and one required a two-stage revision for early deep infection. (Hip International 2005; 15: 155-8) KEY WORDS: Hip resurfacing, Revision surgery, Failure modalities INTRODUCTION Over the course of the last fifty years, various attempts have been made to produce a viable resurfacing implant, with the Smith Peterson cup representing one of the earliest. Sir John Charnley himself experimented with a resurfacing design using polyethylene components but was forced to abandon the concept after a series of early failures. In recent years there has been a resurgence of interest in the concept of hip resurfacing. Proponents of hip resurfacing cite reduced blood loss, non-violation of the proximal femoral shaft and reduction of proximal femoral stress shielding as benefits of the technique (1,2). The modern era of resurfacing began in the early 1990s with the introduction of metal-on-metal components with hybrid fixation. Hybrid fixation combines an osteo integrating acetabular component with a cemented femoral component. A new generation of prosthesis designers attempted to overcome earlier disappointments with careful attention to materials and design. Between January 1996 and July 2002, 60 patients (65 hips) were treated in our unit by five consultant surgeons, using the Corin cobalt chrome metal-on-metal hip resurfacing. These patients were the subjects of our study. The Corin acetabular component is an uncemented, hydroxyapatite-coated, osteo-integrating device. The femoral component is secured with polymethylmethacrylate cement. PATIENTS AND METHODS This study was based on 65 consecutive hip resurfacing cases (60 patients) identified from the theatre logbook. The case notes and radiographs of these patients were studied retrospectively. Fifty-nine patients were also contacted at home by telephone to determine their current status. One patient was lost to follow-up. The Cormet Hip resurfacing (Corin, UK) was used in all 65 cases. Forty-one procedures (63%) were performed on male patients and 24 (37%) on female. Patient demographics are summarised in Table 1. The average age of our patients at the time of primary surgery was 55 years. The mean follow-up was 51 months (range 36 to 108 months). All five of the consultants involved had attended an appropriate course before commencing hip resurfacing. They also had experience of working with colleagues in the region . . .

GOV.uk Independent report, December 2020 This advice is provided to facilitate the development of policy on COVID-19 vaccination in the UK. The Joint Committee on Vaccination and Immunisation (JCVI) advises that the first priorities for any COVID-19 vaccination programme should be the prevention of COVID-19 mortality and the protection of health and social care staff and systems. Secondary priorities could include vaccination of those at increased risk of hospitalisation and at increased risk of exposure, and to maintain resilience in essential public services. This document sets out a framework for refining future advice on a national COVID-19 vaccination strategy. This advice has been developed based on: a review of UK epidemiological data on the impact of the COVID-19 pandemic so far (see reference 1) data on demographic and clinical risk factors for mortality and hospitalisation from COVID-19 (see references 2 to 3) data on occupational exposure (see references 4 to 7) a review on vaccine inequalities associated with COVID-19 (see reference 8) Phase 1, 2 and 3 data on the Pfizer/BioNTech mRNA vaccine and headline phase III results on the AstraZeneca vaccine, Phase 1 and 2 data on other developmental COVID-19 vaccines (see references 9 to 18) mathematical modelling on the potential impact of different vaccination programmes (see reference 19) Considerations Pfizer/BioNTech vaccine The committee has reviewed unpublished Phase 1, 2 and 3 safety and efficacy data for the Pfizer/BioNTech mRNA vaccine. The vaccine appears to be safe and well-tolerated, and there were no clinically concerning safety observations. The data indicates high efficacy in all age groups (16 years and over), including encouraging results in older adults. The committee advises that this vaccine be used in the first phase of the programme, according to the priority order set out below. While there is some evidence to indicate high levels of short-term protection from a single dose of vaccine, a two-dose vaccine schedule is currently advised in accordance with regulatory approval. This statement will be updated following consideration of Phase 3 safety and efficacy data on other COVID-19 vaccines. Direct protection versus transmission reduction JCVI has considered a number of different vaccination strategies, including those targeting transmission and those targeted at providing direct protection to persons most at risk. In order to interrupt transmission, mathematical modelling indicates that we would need to vaccinate a large proportion of the population with a vaccine which is highly effective at preventing infection (transmission). At the start of the vaccination programme, good evidence on the effects of vaccination on transmission will not be available, and vaccine availability will be more limited. The best use of available vaccine will also, in part, be dependent on the point in the pandemic the UK is at. Given the current epidemiological situation in the UK, all evidence indicates that the best option for preventing morbidity and mortality in the initial phase of the programme is to directly protect persons most at risk of morbidity and mortality. Age Current evidence strongly indicates that the single greatest risk of mortality from COVID-19 is increasing age and that the risk increases exponentially with age (see references 1 to 3). Mathematical modelling indicates that the optimal strategy for minimising future deaths or quality adjusted life year (QALY) losses is to offer vaccination to older age groups first. These models assume an available vaccine is both safe and effective in older adults (see reference 19). Data also indicate that the absolute risk of mortality is higher in those over 65 years than that seen in the majority of younger adults with an underlying health condition (see below). Accordingly, the Committee’s advice largely prioritises based on age. Age-based programmes are usually easier to implement and therefore achieve higher vaccine uptake. An age-based programme is also likely to increase uptake in those with clinical risk factors as the prevalence of these increases with age. Older adults resident in care homes There is clear evidence that those living in residential care homes for older adults have been disproportionately affected by COVID-19 (see references 20 to 23) as they have had a high risk of exposure to infection and are at higher clinical risk of severe disease and mortality. Given the increased risk of outbreaks, morbidity and mortality in these closed settings, these adults are considered to be at very high risk. The committee’s advice is that this group should be the highest priority for vaccination. Vaccination of residents and staff at the same time is considered to be a highly efficient strategy within a mass vaccination programme with the greatest potential impact (see below). Health and social care workers Frontline health and social care workers are at increased personal risk of exposure to infection with COVID-19 and of transmitting that infection to susceptible and vulnerable patients in health and social care settings. The committee considers frontline health and social care workers who provide care to vulnerable people a high priority for vaccination. Protecting them protects the health and social care service and recognises the risks that they face in this service. Even a small reduction in transmission arising from vaccination would add to the benefits of vaccinating this population, by reducing transmission from health and social care workers to multiple vulnerable patients and other staff members. This group includes those working in hospice care and those working temporarily in the COVID-19 vaccination programme who provide face-to-face clinical care. There is evidence that infection rates are higher in residential care home staff (see references 20 to 23), than in those providing domiciliary care or in healthcare workers. Care home workers are therefore considered a very high priority for vaccination. Prioritisation amongst health and social care workers Frontline health and social care workers at high risk of acquiring infection, at high individual risk of developing serious disease, or at risk of transmitting infection to multiple vulnerable persons or other staff in a healthcare environment, are considered of higher priority for vaccination than those at lower risk. This prioritisation should be taken into account during vaccine deployment. Clinically extremely vulnerable (shielding patients) Individuals considered extremely clinically vulnerable have been shielding for much of the pandemic (see reference 24) . This means that available data are likely to underestimate the risk in this group. Many of those who are clinically extremely vulnerable are in the oldest age groups and will be among the first to receive vaccine. Considering data from the first wave in the UK, the overall risk of mortality for clinically extremely vulnerable younger adults is estimated to be roughly the same as the risk to persons aged 70 to 74 years. Given the level of risk seen in this group as a whole, JCVI advises that persons aged less than 70 years who are clinically extremely vulnerable should be offered vaccine alongside those aged 70 to 74 years of age. There are 2 key exceptions to this, pregnant women with heart disease and children (see below). Many individuals who are clinically extremely vulnerable will have some degree of immunosuppression or be immunocompromised and may not respond as well to the vaccine. Therefore, those who are clinically extremely vulnerable should continue to follow government advice on reducing their risk of infection. Consideration has been given to vaccination of household contacts of immunosuppressed individuals. However, at this time there are no data on the size of the effect of COVID-19 vaccines on transmission. Evidence is expected to accrue during the course of the vaccine programme, and until that time the committee is not in a position to advise vaccination solely on the basis of indirect protection. Once sufficient evidence becomes available the committee will consider options for a cocooning strategy for immunosuppressed individuals, including whether any specific vaccine is preferred in this population. Pregnancy There are no data as yet on the safety of COVID-19 vaccines in pregnancy, either from human or animal studies. Given the lack of evidence, JCVI favours a precautionary approach, and does not currently advise COVID-19 vaccination in pregnancy. Women should be advised not to come forward for vaccination if they may be pregnant or are planning a pregnancy within three months of the first dose. Data are anticipated which will inform discussions on vaccination in pregnancy. JCVI will review these as soon as they become available. Children Following infection, almost all children will have asymptomatic infection or mild disease. There is very limited data on vaccination in adolescents, with no data on vaccination in younger children, at this time. The committee advises that only those children at very high risk of exposure and serious outcomes, such as older children with severe neuro-disabilities that require residential care, should be offered vaccination. Clinicians should discuss the risks and benefits of vaccination with a person with parental responsibility, who should be told about the paucity of safety data for the vaccine in children aged under 16 years. More detail on vaccination in children is set out in the Green Book – Immunisation Against Infectious Disease. Underlying health conditions There is good evidence that certain underlying health conditions increase the risk of morbidity and mortality from COVID-19. When compared to persons without underlying health conditions, the absolute increased risk in those with underlying health conditions is considered generally to be lower than the increased risk in persons over the age of 65 years (with the exception of the clinically extremely vulnerable). The committee’s advice is to offer vaccination to those aged 65 years and over followed by those in clinical risk groups aged 16 years and over. The risk groups identified by the committee are set out below: chronic respiratory disease, including chronic obstructive pulmonary disease (COPD), cystic fibrosis and severe asthma chronic heart disease (and vascular disease) chronic kidney disease chronic liver disease chronic neurological disease including epilepsy Down’s syndrome severe and profound learning disability diabetes solid organ, bone marrow and stem cell transplant recipients people with specific cancers immunosuppression due to disease or treatment asplenia and splenic dysfunction morbid obesity severe mental illness Individuals within these risk groups who are clinically extremely vulnerable are discussed separately (see above). Further advice on risk groups, including clear definitions, are set out in the Green Book – Immunisation Against Infectious Disease. Mitigating inequalities Multiple social and societal drivers are recognised to contribute towards increased risk from COVID-19. JCVI considered it important to understand the factors underlying health inequalities in COVID-19 giving due consideration to relevant scientific evidence, ethical principles and vaccine programme deliverability. The issues considered are set out in annex A. There is clear evidence that certain black, Asian and minority ethnic (BAME) groups have higher rates of infection, and higher rates of serious disease, morbidity and mortality. There is no strong evidence that ethnicity by itself (or genetics) is the sole explanation for observed differences in rates of severe illness and deaths. What is clear is that certain health conditions are associated with increased risk of serious disease, and these health conditions are often overrepresented in certain BAME groups. It is also clear that societal factors, such as occupation, household size, deprivation, and access to healthcare can increase susceptibility to COVID-19 and worsen outcomes following infection. These factors are playing a large role in the inequalities being seen with COVID-19. Good vaccine coverage in BAME groups will be the most important factor within a vaccine programme in reducing inequalities for this group. Prioritisation of persons with underlying health conditions will also provide for greater vaccination of BAME communities who are disproportionately affected by such health conditions. The committee’s advice is for NHS England and Improvement, the Department of Health and Social Care, Public Health England and the devolved administrations to work together to ensure that inequalities are identified and addressed in implementation. This could be through culturally competent and tailored communications and flexible models of delivery, aimed at ensuring everything possible is done to promote good uptake in BAME groups and in groups who may experience inequalities in access to, or engagement with, healthcare services. These tailored implementation measures should be applied across all priority groups during the vaccination programme. Occupational vaccination (other than frontline health and social care workers) The committee considered evidence on the risk of exposure and risk of mortality by occupation. Under the priority groups advised below, those over 50 years of age, and all those 16 years of age and over in a risk group, would be eligible for vaccination within the first phase of the programme. This prioritisation captures almost all preventable deaths from COVID-19, including those associated with occupational exposure to infection. As such, JCVI does not advise further prioritisation by occupation during the first phase of the programme. Occupational prioritisation could form part of a second phase of the programme, which would include healthy individuals from 16 years of age up to 50 years of age, subject to consideration of the latest data on vaccine safety and effectiveness. The impact of vaccine delivery on non-pharmaceutical interventions In a situation of constrained vaccine supply, population level protection will not be achievable immediately. Once we have evidence of the impact of the programme on morbidity and mortality amongst vulnerable persons, the initial phase of the vaccination programme could allow the subsequent relaxation of non-pharmaceutical interventions in some sectors of the population. Government advice on non-pharmaceutical interventions should continue to be followed. Vaccine priority groups: advice on 2 December 2020 Phase 1 – direct prevention of mortality and supporting the NHS and social care system JCVI advises that the first priorities for the COVID-19 vaccination programme should be the prevention of mortality and the maintenance of the health and social care systems. As the risk of mortality from COVID-19 increases with age, prioritisation is primarily based on age. The order of priority for each group in the population corresponds with data on the number of individuals who would need to be vaccinated to prevent one death, estimated from UK data obtained from March to June 2020 (see reference 3). This priority list is as follows: residents in a care home for older adults and their carers all those 80 years of age and over and frontline health and social care workers all those 75 years of age and over all those 70 years of age and over and clinically extremely vulnerable individuals[footnote 1] all those 65 years of age and over all individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality all those 60 years of age and over all those 55 years of age and over all those 50 years of age and over It is estimated that taken together, these groups represent around 99% of preventable mortality from COVID-19. JCVI advises that implementation of the COVID-19 vaccine programme should aim to achieve high vaccine uptake. An age-based programme will likely result in faster delivery and better uptake in those at the highest risk. Implementation should also involve flexibility in vaccine deployment at a local level with due attention to: mitigating health inequalities, such as might occur in relation to access to healthcare and ethnicity vaccine product storage, transport and administration constraints exceptional individualised circumstances availability of suitable approved vaccines, for example for specific age cohorts JCVI appreciates that operational considerations, such as minimising wastage, may require a flexible approach, where decisions are taken in consultation with national or local public health experts. To be assured that outcome is maximised however, JCVI would like to see early and regular comprehensive vaccine coverage data so that the Committee can respond if high priority risk groups are unable to access vaccination in a reasonable time frame. The next phase Further reduction in hospitalisation and targeted vaccination of those at high risk of exposure and/or those delivering key public services As the first phase of the programme is rolled out in the UK, additional data will become available on the safety and effectiveness of COVID-19 vaccines. These data will provide the basis for consideration of vaccination in groups that are at lower risk of mortality from COVID-19. The committee is currently of the view that the key focus for the second phase of vaccination could be on further preventing hospitalisation. Vaccination of those at increased risk of exposure to SARS-CoV-2 due to their occupation could also be a priority in the next phase. This could include: first responders the military those involved in the justice system teachers transport workers public servants essential to the pandemic response. Priority occupations for vaccination are considered an issue of policy, rather than for JCVI to advise on. JCVI asks that DHSC consider occupational vaccination in collaboration with other government departments. Wider use of COVID-19 vaccines will provide a better understanding of whether they can prevent infection and onward transmission in the population. Data on vaccine impact on transmission, along with data on vaccine safety and effectiveness, will potentially allow for consideration of vaccination across the rest of the population. As trials in children and pregnant women are completed, we will also gain a better understanding of the safety and effectiveness of the vaccines in these persons. Further work JCVI will continually monitor data on vaccines in development. As more Phase 3 data becomes available on candidate COVID-19 vaccines the committee will be able to prepare further advice for policy makers in the UK. JCVI will review data on vaccine coverage, in particular focussing on inequalities, and the impact of actions being undertaken to mitigate inequalities. Vaccine safety will be continually monitored by the MHRA and PHE, and JCVI will regularly review data on vaccine safety as the programme rolls out. Vaccine efficacy and any potential impacts on transmission will be monitored by PHE. Data will be considered at the earliest opportunity to facilitate discussions on prioritisation after the first phase of the programme. Background JCVI met to consider COVID-19 vaccination on: 7 May 3 June 6 July 1 September 29 November 30 November 1 December 2020 Between 24 September 2020 and 19 November 2020, a JCVI COVID-19 sub-committee met weekly to consider key issues in greater depth. The advice provided is to support the government in development of a vaccine strategy for the procurement and delivery of a vaccination programme to the population. SARS-CoV-2 (COVID-19) COVID-19 disease first emerged as a cause of severe respiratory infection in Wuhan, China in late 2019. The first 2 cases in the UK were seen in late January 2020. In March 2020, the World Health Organisation (WHO) declared a SARS-Cov-2 pandemic. In adults, the clinical picture varies widely. A significant proportion of individuals are likely to have mild symptoms and may be asymptomatic at the time of diagnosis. Symptoms are commonly reported as a new onset of cough and fever, but may include headache, loss of smell, nasal obstruction, lethargy, myalgia, rhinorrhoea, taste dysfunction, sore throat, diarrhoea, vomiting and confusion. Fever may not be reported in all symptomatic individuals. Progression of disease, multiple organ failure and death will occur in some individuals. As with other Coronaviruses, SARS-CoV-2 is an RNA virus which encodes four major structural proteins. Most vaccine candidates focus on immunisation with the spike glycoprotein, which is the main target for neutralising antibodies following infection. Neutralising antibodies that block viral entry into host cells by preventing interaction between the spike protein and the host cell are expected to be protective. Pfizer/BioNTech vaccine The Pfizer/BioNTech vaccine is a lipid nanoparticle-formulated mRNA vaccine. The mRNA encodes the SARS-CoV-2 full length spike protein. The mRNA in the vaccine is translated and transcribed by the body to produce the spike protein. The protein then acts as an intracellular antigen to stimulate the immune response. The mRNA in the vaccine is normally degraded within a few days and cannot incorporate into the host genome. Data from the Pfizer/BioNTech vaccine trials undertaken in over 40,000 individuals indicate high vaccine efficacy, with no serious safety concerns observed. AstraZeneca COVID-19 vaccine AstraZeneca COVID-19 vaccine uses a replication deficient chimpanzee adenovirus as a vector that encodes the full-length SARS-CoV2 spike protein. Chimpanzee adenoviruses are non-enveloped viruses, meaning that the glycoprotein antigen is not present on the surface of the vector, but is only expressed at high levels once the vector enters the target cells. Genes are inserted to render the virus replication incompetent, and to enhance immunogenicity. Once the vector is in the nucleus, mRNA encoding the spike protein is produced that then enters the cytoplasm. This leads to translation of the target protein which acts as an intracellular antigen. Headline data from vaccine trials undertaken indicate high vaccine efficacy, with no serious safety events related to the vaccine. After JCVI has been given the opportunity to review Phase 3 data on this vaccine, this statement will be updated. Other vaccines in development Other COVID-19 vaccines are in development, with some in late stage trials. When sufficient data on vaccine safety and efficacy are available, these will be considered by JCVI and this statement will be updated. References National COVID-19 surveillance reports Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020 Aug;584(7821):430-436. Clift AK, Coupland CAC, Keogh RH et al. Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study. BMJ. 2020 Oct 20;371:m3731. Coronavirus (COVID-19) related deaths by occupation, before and during lockdown, England and Wales: deaths registered between 9 March and 30 June 2020, Office for National Statistics Meyerowitz EA, Richterman A, Gandhi RT et al. Transmission of SARS-CoV-2: A Review of Viral, Host, and Environmental Factors. Ann Intern Med. 2020 Sep 17:M20-5008. Lally C. COVID-19 and occupational risk Mutambudzi M, Niedzwiedz C, Macdonald et al. Occupation and risk of severe COVID-19: prospective cohort study of 120,075 UK Biobank participants Public Heath England report – Beyond the data: understanding the impact of COVID-19 on BAME groups Jackson LA, Anderson EJ, Rouphael NG et al. An mRNA Vaccine against SARS-CoV-2 - Preliminary Report. N Engl J Med. 2020 Nov 12;383(20):1920-1931. Corbett KS, Flynn B, Foulds KE et al. Evaluation of the mRNA-1273 Vaccine against SARS-CoV-2 in Nonhuman Primates. N Engl J Med. 2020 Oct 15;383(16):1544-1555. Anderson EJ, Rouphael NG, Widge AT et al. mRNA-1273 Study Group. Safety and Immunogenicity of SARS-CoV-2 mRNA-1273 Vaccine in Older Adults. N Engl J Med. 2020 Sep 29. van Doremalen N, Lambe T, Spencer A et al. ChAdOx1 nCoV-19 vaccine prevents SARS-CoV-2 pneumonia in rhesus macaques. Nature. 2020 Jul 30. Folegatti PM, Ewer KJ, Aley PK et al. Oxford COVID Vaccine Trial Group. Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial. Lancet. 2020 Aug 15;396(10249):467-478. Ramasamy M, Minassian A, Ewer K et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): a single-blind, randomised, controlled, phase 2/3 trial. Lancet Nov 18 2020. Mulligan MJ, Lyke KE, Kitchin N et al. Phase 1/2 study of COVID-19 RNA vaccine BNT162b1 in adults. Nature. 2020 Aug 12. Sahin U, Muik A, Derhovanessian E et al. Concurrent human antibody and T H 1 type T-cell responses elicited by a COVID-19 RNA vaccine. medRxiv [Preprint]. 2020 July 20. Walsh EE, Frenck R, Falsey AR et al. RNA-Based COVID-19 Vaccine BNT162b2 Selected for a Pivotal Efficacy Study. medRxiv [Preprint]. 2020 Aug 20. Keech C, Albert G, Cho I et al. Trial of a SARS-CoV-2 Recombinant Spike Protein Nanoparticle Vaccine. N Engl J Med. 2020 Sep 2. Moore S, Hill E, Dyson L et al. Modelling optimal vaccination strategy for SARS-CoV-2 in the UK. Ladhani SN, Chow JY, Janarthanan R et al. Investigation of SARS-CoV-2 outbreaks in six care homes in London, April 2020. EClinicalMedicine. 2020 Sep 9:100533. Ladhani SN, Chow JY, Janarthanan R et al. London Care Home Investigation Team. Increased risk of SARS-CoV-2 infection in staff working across different care homes: enhanced CoVID-19 outbreak investigations in London care Homes. J Infect. 2020 Jul 29;81(4):621-4. Graham NSN, Junghans C, Downes R, et al. SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes. J Infect. 2020 Sep;81(3):411-419. Vivaldi 1: coronavirus (COVID-19) care homes study report Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19 Updated 2 December 2020

NHS, December 2020 A coronavirus (COVID-19) vaccine developed by Pfizer/BioNTech has been approved for use in the UK. The vaccine will be made available from next week. The vaccine has met strict standards of safety, quality and effectiveness set out by the independent Medicines and Healthcare products Regulatory Agency (MHRA). Other vaccines are being developed. They will only be available on the NHS once they have been thoroughly tested to make sure they are safe and effective. Vaccine safety Any coronavirus vaccine that is approved must go through all the clinical trials and safety checks all other licensed medicines go through. The UK has some of the highest safety standards in the world. Vaccines will only be used if they are approved by the MHRA. The MHRA has been monitoring every stage of coronavirus vaccine development. So far, thousands of people have been given a coronavirus vaccine and no serious side effects or complications have been reported. Who will get the vaccine The NHS will start giving the coronavirus vaccine as soon as it is available. You will be contacted when it's your turn. At first, the vaccine will be offered to people who are most at risk from coronavirus, before being offered more widely. We expect the vaccine will first be offered to: people who live in care homes and care home workers people aged 80 and over health and social care workers in England The final decision on who will get the vaccine first will follow advice from the Joint Committee on Vaccination and Immunisation (JCVI). - - -

Surgery performed by Mr Trevor Lawrence Orthopaedic Consultant at University Hospital Birmingham Meticulous attention to cement technique is essential to long-term survivorship, and indeed to pronounced pain relief and improved quality of life which the regained physical mobility can bring. The vast majority of my patients return to an active lifestyle, with their implants expected to last a lifetime. Even patients in their 30s or 40s can expect life-long use from their artificial joints.

Authors Kanai Garala, Tarek Boutefnouchet, Rishanthanan Amblawaner, Trevor Lawrence Research: ACETABULAR RECONSTRUCTION USING A COMPOSITE LAYER OF IMPACTED CANCELLOUS ALLOGRAFT BONE AND CEMENT First published in Sage Journals July 17, 2020 ABSTRACT Background: Revision total hip arthroplasty (rTHA) is often complex and has a less reliable outcome than primary total hip arthroplasty. Acetabular reconstruction remains a challenge because of the variable amount of bone loss. This study describes and evaluates a novel technique of acetabular reconstruction using composite bone grafting. Surgery performed by Mr Trevor Lawrence Orthopaedic Consultant at University Hospital Birmingham Patients and methods: Between June 2005 and January 2012, 108 consecutive patients underwent revision hip arthroplasty in which the acetabular component was revised using composite bone grafting. Of these, 24 were lost to follow-up leaving 84 in the study with a minimum 5-year follow-up. There were 54 women and 30 men with a mean age of 70.1 (31–91) years. All patients were assessed clinically and radiologically after a minimum of 5 years. The primary outcome measures were rate of re-revision, patient-reported outcomes and radiological evidence of loosening. Results: The mean follow-up after revision surgery was 6.9 years (5–10). At operation, 60 patients had an acetabular defect of AAOS stage 3 or more. There was no evidence of loosening in 69 revision acetabular components; 12 showed evidence of non-progressive loosening and 3 patients underwent a re-revision procedure (2 for infection, 1 recurrent dislocation). The mean postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) was 89.11/100 (95% CI, 87.8–90.5). Scores were significantly improved in patients with a more extensive preoperative defect (p = 0.006). The overall patient satisfaction rate at final follow-up was very high. Conclusions: Composite impaction grafting using a layered cement and bone graft technique can give satisfactory clinical and radiological outcomes in the medium- to long-term. Keywords: Acetabular reconstruction, cemented acetabular fixation, clinical, impaction grafting, implant survival, radiological outcomes, total hip arthroplasty To read this paper in full, please visit Sage Journals purchase content page. - - - REFERENCES 1. Havelin, LI, Fenstad, AM, Salomonsson, R, et al. The Nordic arthroplasty register association: a unique collaboration between 3 national hip arthroplasty registries with 280,201 THRs. Acta Orthop 2009; 80: 393–401. Google Scholar | Crossref | Medline | ISI 2. Garcia-Cimbrelo, E, Diez-Vazquez, V, Madero, R, et al. Progression of radiolucent lines adjacent to the acetabular component and factors influencing migration after Charnley low-friction total hip arthroplasty. J Bone Joint Surg Am 1997; 79: 1373–1380. Google Scholar | Crossref | Medline | ISI 3. 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