Orthopaedic Update

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

So is open or arthroscopic technique better?

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

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

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

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

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

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

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

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

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

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

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

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

Questions and answers on metal on metal implants

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

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

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

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

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

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

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

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

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

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

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

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

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

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