Anil Gambhir - Academia.edu (original) (raw)

Papers by Anil Gambhir

Research paper thumbnail of Comparative analysis of conventional and IRP theory based Shunt APF for 3P3W system

2014 IEEE 6th India International Conference on Power Electronics (IICPE), 2014

Research paper thumbnail of Clinical experience of revision of metal on metal hip arthroplasty for aseptic lymphocyte dominated vasculitis associated lesions (ALVAL)

Hip international : the journal of clinical and experimental research on hip pathology and therapy

There has been growing concern regarding the systemic and local effects of metal ions released fr... more There has been growing concern regarding the systemic and local effects of metal ions released from metal-on-metal hip resurfacings and total hip replacements, including the development of aseptic lymphocyte dominated vasculitis associated lesions (ALVAL). We describe our experience of treating 13 patients with failed metal on metal bearing hip prostheses secondary to this condition. Hip revision occurred at mean of 45 months following primary surgery. Groin pain was present in all patients. Other common features included large bursal swelling and mechanical symptoms. 3 patients developed their symptoms immediately postoperatively. The mean time to presentation was 21 months. Radiographic abnormalities noted included 3 patients with cup loosening and 2 patients with neck thinning. The mean cup inclination was 52 degrees. Surgical findings included bursal swellings and creamy brown fluid. Osteolysis was rarely seen. 12 revisions were achieved with primary implants and all patients ha...

Research paper thumbnail of Medium-term results with the Press Fit Condylar (PFC) Sigma knee prosthesis the Wrightington experience

Acta orthopaedica Belgica, 2007

The PFC Sigma total knee was introduced in 1997, incorporating a number of design changes. We rep... more The PFC Sigma total knee was introduced in 1997, incorporating a number of design changes. We report the mid-term results of a consecutive series of PFC Sigma knee arthroplasties performed between November 1997 and December 1998. Out of a total of 156 patients (166 knees), 5 patients (5 knees) were lost to follow-up and 6 patients (6 knees) died of unrelated causes. This left 145 patients (155 knees), 90 female and 55 male, with a mean age of 70 years (range, 53-88) and an average follow-up of 90 months (range, 84-96). Posterior cruciate retaining components were used in 136 knees (88%) and posterior-stabilized in 19 (12%). The patella was resurfaced in 74 (48%) knees. Follow-up was at 3, 6 and 12 months, then yearly. Preoperative American Knee Society and Oxford scores were compared with follow-up scores. The Knee Society radiological score was used for radiographic assessment. One knee (0.6%) was revised due to aseptic loosening. One knee (0.6%) had superficial wound infection, wh...

Research paper thumbnail of Distally locked, fully hydroxyapatite coated modular long stems in salvage revision hip arthroplasty: a report of early experience

European Journal of Orthopaedic Surgery & Traumatology, 2009

Introduction Revision hip arthroplasty can sometimes be very challenging due to poor proximal bo... more Introduction Revision hip arthroplasty can sometimes be very challenging due to poor proximal bonestock following multiple revisions, bone resorption, infection or peri-prosthetic fracture. The challenge for the surgeon is to achieve fixation of the implant distally in healthy bone, yet allow bone in-growth proximally to encourage regeneration of the deficient femur. We present our early experiences with a fully hydroxyapatite coated modular long stems with distal screw locking (REEF, Depuy) in difficult revision scenarios. Methods A total of 21 patients with a mean age of 68 (range 37–86) were followed up for a mean period of 19 months (9–36 months). Revision was performed for aseptic loosening with severe proximal bone loss in 14 cases (67%), peri-prosthetic fractures in 6 cases (28%) and 1 case with infection (5%). Oxford hip score was determined for each patient. Radiographs were assessed for the formation of spot welds, cortical hypertrophy, radiolucent lines, subsidence of implants, calcar resorption and heterotopic ossification. Results One patient underwent re-revision due to initial undersizing of the stem. Radiological review of all the femoral components, including the one re-revision showed stable bony in-growth and no radiolucent lines in any zone. The incidence of spot weld formation and cortical hypertrophy was highest in zone 6. One patient had persistent thigh pain and subsidence of 2 cm occurred in one case (5%). There were no dislocations, infections or calcar resorption. Three patients developed Grade 1 and three patients developed Grade 2 heterotopic ossification. Conclusion Improvement in stem design, surface coating, distal locking and modularity allow independent fitting of the diaphysis and metaphysis, adjustment of length, offset and version to facilitate more biological reconstruction of proximal femur. Early results with this stem in salvage revisions appear promising.

Research paper thumbnail of Transient bilateral osteoporosis of the hip mistaken for septic arthritis: unusual presentation in a non-pregnant woman

European Journal of Orthopaedic Surgery & Traumatology, 2003

Transient osteoporosis of the hip is an uncommon condition that affects young and middleaged men,... more Transient osteoporosis of the hip is an uncommon condition that affects young and middleaged men, and women during the third trimester of pregnancy. Its incidence and aetiology in pregnancy is unknown. It is bilateral in approximately one third of patients. The patient characteristically gives a history of gradual onset of groin pain increasing in severity over a number of weeks, with pain worse on weight bearing. There is no history of trauma or systemic upset. Differential diagnoses are avascular necrosis of the hip, neoplasm, osteomyelitis and synovitis. Clinical diagnosis can be elusive, and symptoms are often misinterpreted leading to unnecessary tests and morbidity. Diagnosis is by radiological investigation. Treatment is conservative, including protected weight bearing, physical therapy and non-steroidal analgesics. We present a highly unusual case of sequential bilateral transient osteoporosis of the hip in a non-pregnant woman. Initial presentation mimicked septic arthritis leading to arthrotomy.

Research paper thumbnail of Intrarater and Interrater Reliability of the Socket Version Marker in Total Hip Replacement

The Open Orthopaedics Journal, 2013

The aim of this study was to evaluate the intraobserver and interobserver variability in determin... more The aim of this study was to evaluate the intraobserver and interobserver variability in determining the socket version using the wire marker. 100 anteroposterior pelvis radiographs of cemented primary total hip replacements were reviewed by two orthopaedic consultants and registrars, twice. Intrarater and interrater reliability were assessed using Cohen's kappa. Intrarater kappas for junior doctors were 0.78 and 0.80, 0.73 and 0.62 for Consultants. Interrater kappas were 0.60 between the two Consultants and 0.63 between the two Junior Doctors. The kappas between Consultant A and Junior Doctor A was 0.61, between Consultant A and Junior Doctor B was 0.59, between Consultant B and Junior Doctor A was 0.53 and between Consultant B and Junior Doctor B was 0.46. Intrarater reliability was substantial for the two junior doctors and the two consultants. Interrater reliability was moderate-to-substantial between the two consultants, between the two junior doctors and between each pair of junior doctors/consultants.

Research paper thumbnail of (i) Evaluation of a painful total hip replacement

Orthopaedics and Trauma, 2009

Total hip replacement is a common and effective operation with a high success rate. This article ... more Total hip replacement is a common and effective operation with a high success rate. This article discusses the aetiology and evaluation of persisting pain after total hip replacement. A thorough history and physical examination and appropriate investigation can determine the cause of the painful total hip replacement in most patients, allowing appropriate treatment.

Research paper thumbnail of Two stage revision knee arthroplasty for infection with massive bone loss. A technique to achieve spacer stability

The Knee, 2012

We report a technique for the intra-operative production of an antibiotic-impregnated cement spac... more We report a technique for the intra-operative production of an antibiotic-impregnated cement spacer, reinforced with an intramedullary nail. The spacer is designed for use in cases where significant bone loss and/or ligamentous instability prevent the formation of a stable joint when using a conventional spacer during a two-stage revision knee arthroplasty. This technique has been performed in eleven patients. Nine patients have subsequently undergone a second-stage procedure. Two patients died of unrelated causes before a second-stage could be performed. In all but one case, the infection has been successfully eradicated and patients remain infection free at a mean follow-up of 32 months (range 21-64 months). We believe that the described technique is an effective alternative to the traditional spacer, in patients with significant bone loss and/or ligamentous instability. It delivers antibiotics locally, while producing a mechanically stable joint, on which the patient can mobilise, maintaining leg length and tissue tensions.

Research paper thumbnail of Intravesicular Bone after Pelvic Fracture

The Journal of Trauma: Injury, Infection, and Critical Care, 2004

... Case Report. Intravesicular Bone after Pelvic Fracture. Malik, Mohammad HA MA, MRCS; Gambhir,... more ... Case Report. Intravesicular Bone after Pelvic Fracture. Malik, Mohammad HA MA, MRCS; Gambhir, Anil K. FRCS(Orth); Clayson, Anthony D. FRCS(Orth). Article Outline. Collapse Box Author Information. ... REFERENCES. 1. Dalal SA, Burgess AR, Siegel JH, et al. ...

Research paper thumbnail of Intraoperative bacterial contamination in operations for joint replacement

The Journal of Bone and Joint Surgery, 1999

All surgical operations have the potential for contamination, and the equipment used can harbour ... more All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.

Research paper thumbnail of The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty

Journal of Bone and Joint Surgery - British Volume, 2007

Heterotopic ossification following joint replacement in the lower limb occurs in 3% to 90% of cas... more Heterotopic ossification following joint replacement in the lower limb occurs in 3% to 90% of cases. Higher grades of heterotopic ossification can result in significant limitation of function and can negate the benefits of joint replacement. The understanding of the pathophysiology of this condition has improved in recent years. It would appear to be related to a combination of systemic and local factors, including over-expression of bone morphogenetic protein-4. There is currently little evidence to support the routine use of prophylaxis for heterotopic ossification in arthroplasty patients, but prophylaxis is recommended by some for high-risk patients. Radiotherapy given as one dose of 7 Gy to 8 Gy, either pre-operatively (< four hours before) or post-operatively (within 72 hours of surgery), appears to be more effective than indometacin therapy (75 mg daily for six weeks). In cases of prophylaxis against recurrent heterotopic ossification following excision, recent work has suggested that a combination of radiotherapy and indometacin is effective. Advances in our understanding of this condition may permit the development of newer, safer treatment modalities.

Research paper thumbnail of The microbiology of infected hip arthroplasty

International Orthopaedics, 2006

Infection following joint replacement surgery although rare presents a challenging problem. Bacte... more Infection following joint replacement surgery although rare presents a challenging problem. Bacterial resistance to antibiotics is an emerging problem. We analysed the microbiology of 337 single-stage revisions for deep infection. Coagulase negative staphylococcus was found to be the predominant organism, although staphylococcus aureus is gaining importance. Gentamicin only provides cover for 64.1% of organisms. Resistance to this commonly used antibiotic prophylaxis is escalating. Fusidic acid and erythromycin provide improved cover. We would suggest on a microbiological basis that these antibiotics be considered for addition to acrylic bone cement. This will provide local antibiotic delivery when performing a revision for deep infection.

Research paper thumbnail of The microbiology of the infected knee arthroplasty

International Orthopaedics, 2010

We describe the results of a retrospective analysis of patients with microbiologically proven inf... more We describe the results of a retrospective analysis of patients with microbiologically proven infection, who underwent revision TKA between 1994 and 2008. Of the 121 patients included in the study, 61 (50%) were male and 60 (50%) were female. The mean age was 71 (range 42-88) years. The most common organisms identified were Coagulase negative Staphylococcus (CNS) (49%) and Staphylococcus aureus (SA) (13%). The prevalence of CNS appears to be increasing, while that of SA and other organisms is decreasing. Vancomycin and teicoplanin were the most effective antibiotics with overall sensitivity rates of 100% and 96%, respectively. The results of our theoretical model suggest that gentamicin combined with vancomycin is the most effective empirical regimen. Staphylococcal species are the most common organisms encountered in deep infection of the knee. Gentamicin combined with vancomycin offers the most comprehensive protection and potentially allows for infected knee arthoplasties to be treated with a one-stage procedure.

Research paper thumbnail of Comfort assessment of personal protection systems during total joint arthroplasty using a novel multi-dimensional evaluation tool

Annals of The Royal College of Surgeons of England, 2006

A number of studies have assessed the usefulness of surgical gowns and exhaust suits with regards... more A number of studies have assessed the usefulness of surgical gowns and exhaust suits with regards to barrier function and protection afforded to healthcare workers from blood strike-through, splashes and aerosols. We have performed a comfort assessment comparison between the Charnley exhaust suit, disposable gown plus visor and the Stryker Steri-Shield system using a newly developed objective multidimensional ergonomic tool designed to measure wearable comfort across the dimensions of emotion, attachment, harm, perceived change, movement and anxiety. The total mean Comfort Rating Scale value for a disposable gown plus visor was 16.1 with a mean dimensional score of 2.7 (range, 0.2-8.4), for the Charnley system the values were 51.4 and 8.6 (range, 5.9-12.8), respectively, and for the Stryker Steri-Shield 15.4 and 2.6 (range, 0.8-5.6). The Steri-Shield system provides the least variation in comfort and, as such, may offer the best combination of comfort, protective qualities and form or style of personal protection equipment for lower limb arthroplasty operations.

Research paper thumbnail of Primary total hip replacement: a comparison of a nationally agreed guide to best practice and current surgical technique as determined by the North West Regional Arthroplasty Register

Annals of The Royal College of Surgeons of England, 2004

In 1999, a statement of best practice in primary total hip replacement was approved by the Counci... more In 1999, a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association (BOA) and by the British Hip Society (BHS) to provide a basis for regional and national auditable standards. We have compared practice in the North West Region of England to this document to ascertain adherence to this guide to best practice. A total of 86 surgeons from 26 hospitals were included in a questionnaire study. A mean of 93.3% of operations were performed in the surgeon's usual theatre. All of these theatres had vertical laminar air flow systems. Of respondents, 42.2% routinely used exhaust suits, 68.1% routinely used impermeable disposable gowns, and 26.1% used impermeable re-usable gowns. The Charnley femoral and acetabular prostheses were the most commonly used prostheses. All surgeons used some form of anti-thromboembolic prophylaxis: 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin--70.7% used a 3-dose regimen over 24 h, 2.6% of surgeons continued antibiotic prophylaxis for 48 h after surgery, and 93.7% of surgeons routinely use antibiotic-loaded cement. All surgeons routinely cleaned, irrigated and dried the acetabulum and femur before cement insertion. Only one surgeon did not use any form of femoral canal occlusion. 69.4% used an intramedullary bone block. Retrograde filling of the femoral shaft by means of a cement gun was practised by 65.1%. This study has demonstrated considerable variation of practice in total hip arthroplasty across the North West Region and significant divergence from the statement of best practice approved by the BOA and BHS. The introduction of a properly funded national hip register will surely help to clarify the effect of such diverse practice on patient outcome. We would recommend that all trusts locally audit their practices and correlate them with these nationally agreed guidelines.

Research paper thumbnail of Management of acetabular peri-prosthetic fractures using posterior column plate fixation and socket revision

Research paper thumbnail of Comparative analysis of conventional and IRP theory based Shunt APF for 3P3W system

2014 IEEE 6th India International Conference on Power Electronics (IICPE), 2014

Research paper thumbnail of Clinical experience of revision of metal on metal hip arthroplasty for aseptic lymphocyte dominated vasculitis associated lesions (ALVAL)

Hip international : the journal of clinical and experimental research on hip pathology and therapy

There has been growing concern regarding the systemic and local effects of metal ions released fr... more There has been growing concern regarding the systemic and local effects of metal ions released from metal-on-metal hip resurfacings and total hip replacements, including the development of aseptic lymphocyte dominated vasculitis associated lesions (ALVAL). We describe our experience of treating 13 patients with failed metal on metal bearing hip prostheses secondary to this condition. Hip revision occurred at mean of 45 months following primary surgery. Groin pain was present in all patients. Other common features included large bursal swelling and mechanical symptoms. 3 patients developed their symptoms immediately postoperatively. The mean time to presentation was 21 months. Radiographic abnormalities noted included 3 patients with cup loosening and 2 patients with neck thinning. The mean cup inclination was 52 degrees. Surgical findings included bursal swellings and creamy brown fluid. Osteolysis was rarely seen. 12 revisions were achieved with primary implants and all patients ha...

Research paper thumbnail of Medium-term results with the Press Fit Condylar (PFC) Sigma knee prosthesis the Wrightington experience

Acta orthopaedica Belgica, 2007

The PFC Sigma total knee was introduced in 1997, incorporating a number of design changes. We rep... more The PFC Sigma total knee was introduced in 1997, incorporating a number of design changes. We report the mid-term results of a consecutive series of PFC Sigma knee arthroplasties performed between November 1997 and December 1998. Out of a total of 156 patients (166 knees), 5 patients (5 knees) were lost to follow-up and 6 patients (6 knees) died of unrelated causes. This left 145 patients (155 knees), 90 female and 55 male, with a mean age of 70 years (range, 53-88) and an average follow-up of 90 months (range, 84-96). Posterior cruciate retaining components were used in 136 knees (88%) and posterior-stabilized in 19 (12%). The patella was resurfaced in 74 (48%) knees. Follow-up was at 3, 6 and 12 months, then yearly. Preoperative American Knee Society and Oxford scores were compared with follow-up scores. The Knee Society radiological score was used for radiographic assessment. One knee (0.6%) was revised due to aseptic loosening. One knee (0.6%) had superficial wound infection, wh...

Research paper thumbnail of Distally locked, fully hydroxyapatite coated modular long stems in salvage revision hip arthroplasty: a report of early experience

European Journal of Orthopaedic Surgery & Traumatology, 2009

Introduction Revision hip arthroplasty can sometimes be very challenging due to poor proximal bo... more Introduction Revision hip arthroplasty can sometimes be very challenging due to poor proximal bonestock following multiple revisions, bone resorption, infection or peri-prosthetic fracture. The challenge for the surgeon is to achieve fixation of the implant distally in healthy bone, yet allow bone in-growth proximally to encourage regeneration of the deficient femur. We present our early experiences with a fully hydroxyapatite coated modular long stems with distal screw locking (REEF, Depuy) in difficult revision scenarios. Methods A total of 21 patients with a mean age of 68 (range 37–86) were followed up for a mean period of 19 months (9–36 months). Revision was performed for aseptic loosening with severe proximal bone loss in 14 cases (67%), peri-prosthetic fractures in 6 cases (28%) and 1 case with infection (5%). Oxford hip score was determined for each patient. Radiographs were assessed for the formation of spot welds, cortical hypertrophy, radiolucent lines, subsidence of implants, calcar resorption and heterotopic ossification. Results One patient underwent re-revision due to initial undersizing of the stem. Radiological review of all the femoral components, including the one re-revision showed stable bony in-growth and no radiolucent lines in any zone. The incidence of spot weld formation and cortical hypertrophy was highest in zone 6. One patient had persistent thigh pain and subsidence of 2 cm occurred in one case (5%). There were no dislocations, infections or calcar resorption. Three patients developed Grade 1 and three patients developed Grade 2 heterotopic ossification. Conclusion Improvement in stem design, surface coating, distal locking and modularity allow independent fitting of the diaphysis and metaphysis, adjustment of length, offset and version to facilitate more biological reconstruction of proximal femur. Early results with this stem in salvage revisions appear promising.

Research paper thumbnail of Transient bilateral osteoporosis of the hip mistaken for septic arthritis: unusual presentation in a non-pregnant woman

European Journal of Orthopaedic Surgery & Traumatology, 2003

Transient osteoporosis of the hip is an uncommon condition that affects young and middleaged men,... more Transient osteoporosis of the hip is an uncommon condition that affects young and middleaged men, and women during the third trimester of pregnancy. Its incidence and aetiology in pregnancy is unknown. It is bilateral in approximately one third of patients. The patient characteristically gives a history of gradual onset of groin pain increasing in severity over a number of weeks, with pain worse on weight bearing. There is no history of trauma or systemic upset. Differential diagnoses are avascular necrosis of the hip, neoplasm, osteomyelitis and synovitis. Clinical diagnosis can be elusive, and symptoms are often misinterpreted leading to unnecessary tests and morbidity. Diagnosis is by radiological investigation. Treatment is conservative, including protected weight bearing, physical therapy and non-steroidal analgesics. We present a highly unusual case of sequential bilateral transient osteoporosis of the hip in a non-pregnant woman. Initial presentation mimicked septic arthritis leading to arthrotomy.

Research paper thumbnail of Intrarater and Interrater Reliability of the Socket Version Marker in Total Hip Replacement

The Open Orthopaedics Journal, 2013

The aim of this study was to evaluate the intraobserver and interobserver variability in determin... more The aim of this study was to evaluate the intraobserver and interobserver variability in determining the socket version using the wire marker. 100 anteroposterior pelvis radiographs of cemented primary total hip replacements were reviewed by two orthopaedic consultants and registrars, twice. Intrarater and interrater reliability were assessed using Cohen's kappa. Intrarater kappas for junior doctors were 0.78 and 0.80, 0.73 and 0.62 for Consultants. Interrater kappas were 0.60 between the two Consultants and 0.63 between the two Junior Doctors. The kappas between Consultant A and Junior Doctor A was 0.61, between Consultant A and Junior Doctor B was 0.59, between Consultant B and Junior Doctor A was 0.53 and between Consultant B and Junior Doctor B was 0.46. Intrarater reliability was substantial for the two junior doctors and the two consultants. Interrater reliability was moderate-to-substantial between the two consultants, between the two junior doctors and between each pair of junior doctors/consultants.

Research paper thumbnail of (i) Evaluation of a painful total hip replacement

Orthopaedics and Trauma, 2009

Total hip replacement is a common and effective operation with a high success rate. This article ... more Total hip replacement is a common and effective operation with a high success rate. This article discusses the aetiology and evaluation of persisting pain after total hip replacement. A thorough history and physical examination and appropriate investigation can determine the cause of the painful total hip replacement in most patients, allowing appropriate treatment.

Research paper thumbnail of Two stage revision knee arthroplasty for infection with massive bone loss. A technique to achieve spacer stability

The Knee, 2012

We report a technique for the intra-operative production of an antibiotic-impregnated cement spac... more We report a technique for the intra-operative production of an antibiotic-impregnated cement spacer, reinforced with an intramedullary nail. The spacer is designed for use in cases where significant bone loss and/or ligamentous instability prevent the formation of a stable joint when using a conventional spacer during a two-stage revision knee arthroplasty. This technique has been performed in eleven patients. Nine patients have subsequently undergone a second-stage procedure. Two patients died of unrelated causes before a second-stage could be performed. In all but one case, the infection has been successfully eradicated and patients remain infection free at a mean follow-up of 32 months (range 21-64 months). We believe that the described technique is an effective alternative to the traditional spacer, in patients with significant bone loss and/or ligamentous instability. It delivers antibiotics locally, while producing a mechanically stable joint, on which the patient can mobilise, maintaining leg length and tissue tensions.

Research paper thumbnail of Intravesicular Bone after Pelvic Fracture

The Journal of Trauma: Injury, Infection, and Critical Care, 2004

... Case Report. Intravesicular Bone after Pelvic Fracture. Malik, Mohammad HA MA, MRCS; Gambhir,... more ... Case Report. Intravesicular Bone after Pelvic Fracture. Malik, Mohammad HA MA, MRCS; Gambhir, Anil K. FRCS(Orth); Clayson, Anthony D. FRCS(Orth). Article Outline. Collapse Box Author Information. ... REFERENCES. 1. Dalal SA, Burgess AR, Siegel JH, et al. ...

Research paper thumbnail of Intraoperative bacterial contamination in operations for joint replacement

The Journal of Bone and Joint Surgery, 1999

All surgical operations have the potential for contamination, and the equipment used can harbour ... more All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.

Research paper thumbnail of The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty

Journal of Bone and Joint Surgery - British Volume, 2007

Heterotopic ossification following joint replacement in the lower limb occurs in 3% to 90% of cas... more Heterotopic ossification following joint replacement in the lower limb occurs in 3% to 90% of cases. Higher grades of heterotopic ossification can result in significant limitation of function and can negate the benefits of joint replacement. The understanding of the pathophysiology of this condition has improved in recent years. It would appear to be related to a combination of systemic and local factors, including over-expression of bone morphogenetic protein-4. There is currently little evidence to support the routine use of prophylaxis for heterotopic ossification in arthroplasty patients, but prophylaxis is recommended by some for high-risk patients. Radiotherapy given as one dose of 7 Gy to 8 Gy, either pre-operatively (< four hours before) or post-operatively (within 72 hours of surgery), appears to be more effective than indometacin therapy (75 mg daily for six weeks). In cases of prophylaxis against recurrent heterotopic ossification following excision, recent work has suggested that a combination of radiotherapy and indometacin is effective. Advances in our understanding of this condition may permit the development of newer, safer treatment modalities.

Research paper thumbnail of The microbiology of infected hip arthroplasty

International Orthopaedics, 2006

Infection following joint replacement surgery although rare presents a challenging problem. Bacte... more Infection following joint replacement surgery although rare presents a challenging problem. Bacterial resistance to antibiotics is an emerging problem. We analysed the microbiology of 337 single-stage revisions for deep infection. Coagulase negative staphylococcus was found to be the predominant organism, although staphylococcus aureus is gaining importance. Gentamicin only provides cover for 64.1% of organisms. Resistance to this commonly used antibiotic prophylaxis is escalating. Fusidic acid and erythromycin provide improved cover. We would suggest on a microbiological basis that these antibiotics be considered for addition to acrylic bone cement. This will provide local antibiotic delivery when performing a revision for deep infection.

Research paper thumbnail of The microbiology of the infected knee arthroplasty

International Orthopaedics, 2010

We describe the results of a retrospective analysis of patients with microbiologically proven inf... more We describe the results of a retrospective analysis of patients with microbiologically proven infection, who underwent revision TKA between 1994 and 2008. Of the 121 patients included in the study, 61 (50%) were male and 60 (50%) were female. The mean age was 71 (range 42-88) years. The most common organisms identified were Coagulase negative Staphylococcus (CNS) (49%) and Staphylococcus aureus (SA) (13%). The prevalence of CNS appears to be increasing, while that of SA and other organisms is decreasing. Vancomycin and teicoplanin were the most effective antibiotics with overall sensitivity rates of 100% and 96%, respectively. The results of our theoretical model suggest that gentamicin combined with vancomycin is the most effective empirical regimen. Staphylococcal species are the most common organisms encountered in deep infection of the knee. Gentamicin combined with vancomycin offers the most comprehensive protection and potentially allows for infected knee arthoplasties to be treated with a one-stage procedure.

Research paper thumbnail of Comfort assessment of personal protection systems during total joint arthroplasty using a novel multi-dimensional evaluation tool

Annals of The Royal College of Surgeons of England, 2006

A number of studies have assessed the usefulness of surgical gowns and exhaust suits with regards... more A number of studies have assessed the usefulness of surgical gowns and exhaust suits with regards to barrier function and protection afforded to healthcare workers from blood strike-through, splashes and aerosols. We have performed a comfort assessment comparison between the Charnley exhaust suit, disposable gown plus visor and the Stryker Steri-Shield system using a newly developed objective multidimensional ergonomic tool designed to measure wearable comfort across the dimensions of emotion, attachment, harm, perceived change, movement and anxiety. The total mean Comfort Rating Scale value for a disposable gown plus visor was 16.1 with a mean dimensional score of 2.7 (range, 0.2-8.4), for the Charnley system the values were 51.4 and 8.6 (range, 5.9-12.8), respectively, and for the Stryker Steri-Shield 15.4 and 2.6 (range, 0.8-5.6). The Steri-Shield system provides the least variation in comfort and, as such, may offer the best combination of comfort, protective qualities and form or style of personal protection equipment for lower limb arthroplasty operations.

Research paper thumbnail of Primary total hip replacement: a comparison of a nationally agreed guide to best practice and current surgical technique as determined by the North West Regional Arthroplasty Register

Annals of The Royal College of Surgeons of England, 2004

In 1999, a statement of best practice in primary total hip replacement was approved by the Counci... more In 1999, a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association (BOA) and by the British Hip Society (BHS) to provide a basis for regional and national auditable standards. We have compared practice in the North West Region of England to this document to ascertain adherence to this guide to best practice. A total of 86 surgeons from 26 hospitals were included in a questionnaire study. A mean of 93.3% of operations were performed in the surgeon's usual theatre. All of these theatres had vertical laminar air flow systems. Of respondents, 42.2% routinely used exhaust suits, 68.1% routinely used impermeable disposable gowns, and 26.1% used impermeable re-usable gowns. The Charnley femoral and acetabular prostheses were the most commonly used prostheses. All surgeons used some form of anti-thromboembolic prophylaxis: 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin--70.7% used a 3-dose regimen over 24 h, 2.6% of surgeons continued antibiotic prophylaxis for 48 h after surgery, and 93.7% of surgeons routinely use antibiotic-loaded cement. All surgeons routinely cleaned, irrigated and dried the acetabulum and femur before cement insertion. Only one surgeon did not use any form of femoral canal occlusion. 69.4% used an intramedullary bone block. Retrograde filling of the femoral shaft by means of a cement gun was practised by 65.1%. This study has demonstrated considerable variation of practice in total hip arthroplasty across the North West Region and significant divergence from the statement of best practice approved by the BOA and BHS. The introduction of a properly funded national hip register will surely help to clarify the effect of such diverse practice on patient outcome. We would recommend that all trusts locally audit their practices and correlate them with these nationally agreed guidelines.

Research paper thumbnail of Management of acetabular peri-prosthetic fractures using posterior column plate fixation and socket revision