BACKGROUND Revision knee replacement (KR) is both challenging for the surgical team and expensive... more BACKGROUND Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making. AIM To provide guidelines for surgeons and units delivering revision KR services. METHODS A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data. RESULTS There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model. CONCLUSIONS Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.
Annals of the Royal College of Surgeons of England, 1999
Inefficiency in surgical training has been identified as a result of low rates of supervision, wi... more Inefficiency in surgical training has been identified as a result of low rates of supervision, with direct teaching of operating by consultants occurring in less than 20% of cases in papers dealing with general surgery and cardiac surgery training. The introduction of an audit system in an orthopaedic training programme was associated with an improvement of teaching from an already high 30% to 40% of cases. A logbook programme was introduced which allows easy analysis of the distribution of experience on an anatomical basis.
Journal of the Royal College of Surgeons of Edinburgh, 2000
We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trau... more We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trauma Unit at the North Staffordshire Royal Infirmary following acute injury. We assessed the patient's level of pain and perception of pain relief in the period from their admission to hospital and surgery, or the first 24 hours as an inpatient using a questionnaire. We found that 54% of patients described their pain as 'severe' or 'the worst possible pain'. Significantly, 36% of patients would have liked more analgesia. We conclude that patients are not receiving the analgesia they require following acute injury.
Aim In knee replacements, restoration of mechanical alignment is essential. Patients with extra-a... more Aim In knee replacements, restoration of mechanical alignment is essential. Patients with extra-articular deformities (EAD) pose challenges in planning knee replacements. We present a method, based on our experience and review of literature on planning knee replacement surgery, in the presence of extra-articular coronal plane deformity of the tibia. Method Retrospective analysis was made of six patients with EAD of the tibia who underwent knee replacement at our centre. Mechanical axis of the tibia is considered and positioning of the tibia component is planned perpendicular to the mechanical axis of the tibia. The integrity of the collaterals determines the need for correction. Tibial resection >15mm from medial or lateral aspect of the tibia is an indication for corrective osteotomy prior to replacement surgery. The hip knee ankle angle (HKA) was noted. Pre-operative, post-operative clinical score, degree of constraints and post-operative complications were recorded. A post-ope...
This large osteology study examined the reliability, reproducibility and correlation between prev... more This large osteology study examined the reliability, reproducibility and correlation between previously described tibial tray rotation alignment lines (including Akagi and Dalury lines). In addition, it described a novel inter-eminence line utilising the tibial plateau inter-condylar eminences as a landmark. A total of 214 post-medieval (18-19th centuries) skeletal tibia were examined. The inter/intra-observer variation and correlation between reference lines were measured. Inter-observer reproducibility was excellent and there were no differences between Akagi, Dalury, and inter-eminence lines. Similarly, intra-observer reliability was excellent for Akagi, Dalury, and inter-eminence lines. Qualitative review of tibial inter-condylar eminences suggested that these could be easily identifiable. When taking the medial angle from a medial-lateral reference line, the Akagi line showed a mean of 96.90° (±10.27), inter-eminence line 94.52° (±12.84), and Dalury line 88.06° (±11.75). The an...
Major lower limb amputation significantly increases the energy cost of walking for patients. Comp... more Major lower limb amputation significantly increases the energy cost of walking for patients. Complications such as osteomyelitis may require further surgery, and can lead to shortening of the stump. In these cases, the aim should be to treat infection without shortening the limb further. We present a series of patients with established osteomyelitis of the amputation stump, managed using a modified Lautenbach technique. Six patients with either above or below knee amputations, in the practice of a single orthopaedic surgeon, were studied. Ages range from 39 to 64 years, and reasons for amputation included infection, pain, and necrosis. All patients had osteomyelitis in the amputation stump confirmed on MRI. At a mean follow-up of 3.75 years (range 7 months to 6 years) all six patients had no clinical or haematological evidence of infection, and had returned to independent living. Stump length was preserved in all cases, including in one patient who underwent two procedures to ensure...
Institutional review board statement: The study was reviewed and approved by the Cardiff and Vale... more Institutional review board statement: The study was reviewed and approved by the Cardiff and Vale Orthopaedic Centre. Informed consent statement: All patients included in the study provided informed consent prior to undergoing surgery.
Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We in... more Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We investigated a novel adjuvant chemical debridement strategy using acetic acid (AA) that seeks to create a hostile environment for microorganisms. We report the first orthopedic in vivo series using an AA soak in infected TKAs. We also investigated the in vitro efficacy of AA against bacteria isolated from these knees. Twenty-three patients with infected TKA were treated with a standard debridement protocol and chemical debridement with a 20-minute AA soak. In parallel, bacteria from infected TKAs were cultured for in vitro susceptibility testing with AA solutions of different concentrations to understand its potential mechanism of action. Intraoperatively, there were no physiological responses during the AA soak or on release of the tourniquet. Postoperatively, there was no increase in analgesic requirements or wound or soft-tissue complications. Clinical follow-up continued for 24 months to monitor recurrent infection. In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19% vol/vol. This study has shown that the use of 3% AA soak, as part of a debridement protocol is safe in patients. While the exact mechanism of action is yet to be determined, AA concentrations as low as 0.19% vol/vol in vitro are sufficient to completely inhibit bacterial growth.
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, Jan 29, 2016
Periprosthetic infection following total knee arthroplasty is a devastating complication, which i... more Periprosthetic infection following total knee arthroplasty is a devastating complication, which is not always satisfactorily resolved by revision surgery. Arthrodesis is a salvage alternative to above-knee amputation or permanent resection arthroplasty. Fixation options include internal compression plating, external fixation, and intramedullary nails. We retrospectively reviewed twelve consecutive cases (9 males, 3 females; mean age, 67 years) of knee arthrodesis with a long intramedullary nail, performed at a single institution between 2003 and 2014. Desired outcomes were the ability to mobilize without pain, solid radiographic fusion, and the eradication of infection. Mean follow-up was 48.5 months (range, 9-120 months). Eleven patients (92 %) demonstrated stable fusion, ten patients (83 %) were ambulatory without pain, and ten patients (83 %) remained without infection at most recent follow-up. Eight patients (67 %) achieved union at an average of 12 months; three required repeat...
Tibial crest osteotomy is an established extensile knee approach. Complications include mal-union... more Tibial crest osteotomy is an established extensile knee approach. Complications include mal-union, non-union, and fixation problems.We have designed a technique aimed at reducing complications through the principles of low-energy osteotomy and suture repair. We reviewed our clinical and radiological results in 159 consecutive patients 181 osteotomies with a mean age of 66 years, and an average follow up of 22 months. Union occurred in all osteotomies (100%) at a mean period of 11 weeks. Proximal migration averaging 11.5 mm occurred in 6 osteotomies (3%). Crest fragmentation occurred in 11 osteotomies (6%), with all cases resulting in uncomplicated union. No extensor mechanism failure or complications related to the suture material occurred. We conclude that this technique results in satisfactory outcomes whilst avoiding hardware-related problems.
We describe a series of three patients who sustained patella tendon injuries in infected total kn... more We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision. The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12 to 20. Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries.
Periprosthetic knee fractures and their complications are expected to increase as the numbers of ... more Periprosthetic knee fractures and their complications are expected to increase as the numbers of knee arthroplasties continue to rise. We report our experience with revision knee arthroplasty for failure of primary fracture treatment. Five periprosthetic knee non-unions and 1 mal-union in 6 patients, with ages ranging from 65 to 83years (average 74.6years) were treated with revision total knee arthroplasty, and were followed up for 3 to 10years (average 4.5years). Union occurred in 8 to 18weeks (average 12.5weeks). All patients were ambulatory at the latest follow-up, with a range of motion averaging 84.2° (P = 0.03), and an Oxford Knee Score averaging 35 (P = 0.03). We conclude that union complications of periprosthetic knee fractures can be satisfactorily addressed with revision arthroplasty.
QUESTION 1A: Is there a role for preoperative skin cleansing with an antiseptic? Consensus: Yes. ... more QUESTION 1A: Is there a role for preoperative skin cleansing with an antiseptic? Consensus: Yes. Preoperative cleansing of the skin with chlorhexidine gluconate (CHG) should be implemented. In the presence of a sensitivity to CHG, or when it is unavailable, it is our consensus that antiseptic soap is appropriate.
Background: Tibial Tubercle Osteotomy has shown much promise in revision total knee replacement. ... more Background: Tibial Tubercle Osteotomy has shown much promise in revision total knee replacement. Methods of repair previously described include screw and wire fixation. Both methods have significant complications. Methods: This article describes suture fixation of the osteotomy using Ethibond sutures placed medially with a lateral periosteal hinge. Results: This method of fixation relies upon an adequate osteotomy segment including the entire insertion of the patella tendon. The lateral periosteal hinge is maintained and adds to the stability of the construct. A minimum of two number 5 Ethibond sutures are passed medially through drill holes to secure the osteotomy segment. No post-operative immobilisation is required. Conclusion: Ethibond sutures provide adequate fixation of the tibial tubercle osteotomy segment in revision knee arthroplasty with reduced risk of complication as compared to conventional fixation methods.
BACKGROUND Revision knee replacement (KR) is both challenging for the surgical team and expensive... more BACKGROUND Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making. AIM To provide guidelines for surgeons and units delivering revision KR services. METHODS A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data. RESULTS There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model. CONCLUSIONS Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.
Annals of the Royal College of Surgeons of England, 1999
Inefficiency in surgical training has been identified as a result of low rates of supervision, wi... more Inefficiency in surgical training has been identified as a result of low rates of supervision, with direct teaching of operating by consultants occurring in less than 20% of cases in papers dealing with general surgery and cardiac surgery training. The introduction of an audit system in an orthopaedic training programme was associated with an improvement of teaching from an already high 30% to 40% of cases. A logbook programme was introduced which allows easy analysis of the distribution of experience on an anatomical basis.
Journal of the Royal College of Surgeons of Edinburgh, 2000
We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trau... more We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trauma Unit at the North Staffordshire Royal Infirmary following acute injury. We assessed the patient's level of pain and perception of pain relief in the period from their admission to hospital and surgery, or the first 24 hours as an inpatient using a questionnaire. We found that 54% of patients described their pain as 'severe' or 'the worst possible pain'. Significantly, 36% of patients would have liked more analgesia. We conclude that patients are not receiving the analgesia they require following acute injury.
Aim In knee replacements, restoration of mechanical alignment is essential. Patients with extra-a... more Aim In knee replacements, restoration of mechanical alignment is essential. Patients with extra-articular deformities (EAD) pose challenges in planning knee replacements. We present a method, based on our experience and review of literature on planning knee replacement surgery, in the presence of extra-articular coronal plane deformity of the tibia. Method Retrospective analysis was made of six patients with EAD of the tibia who underwent knee replacement at our centre. Mechanical axis of the tibia is considered and positioning of the tibia component is planned perpendicular to the mechanical axis of the tibia. The integrity of the collaterals determines the need for correction. Tibial resection >15mm from medial or lateral aspect of the tibia is an indication for corrective osteotomy prior to replacement surgery. The hip knee ankle angle (HKA) was noted. Pre-operative, post-operative clinical score, degree of constraints and post-operative complications were recorded. A post-ope...
This large osteology study examined the reliability, reproducibility and correlation between prev... more This large osteology study examined the reliability, reproducibility and correlation between previously described tibial tray rotation alignment lines (including Akagi and Dalury lines). In addition, it described a novel inter-eminence line utilising the tibial plateau inter-condylar eminences as a landmark. A total of 214 post-medieval (18-19th centuries) skeletal tibia were examined. The inter/intra-observer variation and correlation between reference lines were measured. Inter-observer reproducibility was excellent and there were no differences between Akagi, Dalury, and inter-eminence lines. Similarly, intra-observer reliability was excellent for Akagi, Dalury, and inter-eminence lines. Qualitative review of tibial inter-condylar eminences suggested that these could be easily identifiable. When taking the medial angle from a medial-lateral reference line, the Akagi line showed a mean of 96.90° (±10.27), inter-eminence line 94.52° (±12.84), and Dalury line 88.06° (±11.75). The an...
Major lower limb amputation significantly increases the energy cost of walking for patients. Comp... more Major lower limb amputation significantly increases the energy cost of walking for patients. Complications such as osteomyelitis may require further surgery, and can lead to shortening of the stump. In these cases, the aim should be to treat infection without shortening the limb further. We present a series of patients with established osteomyelitis of the amputation stump, managed using a modified Lautenbach technique. Six patients with either above or below knee amputations, in the practice of a single orthopaedic surgeon, were studied. Ages range from 39 to 64 years, and reasons for amputation included infection, pain, and necrosis. All patients had osteomyelitis in the amputation stump confirmed on MRI. At a mean follow-up of 3.75 years (range 7 months to 6 years) all six patients had no clinical or haematological evidence of infection, and had returned to independent living. Stump length was preserved in all cases, including in one patient who underwent two procedures to ensure...
Institutional review board statement: The study was reviewed and approved by the Cardiff and Vale... more Institutional review board statement: The study was reviewed and approved by the Cardiff and Vale Orthopaedic Centre. Informed consent statement: All patients included in the study provided informed consent prior to undergoing surgery.
Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We in... more Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We investigated a novel adjuvant chemical debridement strategy using acetic acid (AA) that seeks to create a hostile environment for microorganisms. We report the first orthopedic in vivo series using an AA soak in infected TKAs. We also investigated the in vitro efficacy of AA against bacteria isolated from these knees. Twenty-three patients with infected TKA were treated with a standard debridement protocol and chemical debridement with a 20-minute AA soak. In parallel, bacteria from infected TKAs were cultured for in vitro susceptibility testing with AA solutions of different concentrations to understand its potential mechanism of action. Intraoperatively, there were no physiological responses during the AA soak or on release of the tourniquet. Postoperatively, there was no increase in analgesic requirements or wound or soft-tissue complications. Clinical follow-up continued for 24 months to monitor recurrent infection. In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19% vol/vol. This study has shown that the use of 3% AA soak, as part of a debridement protocol is safe in patients. While the exact mechanism of action is yet to be determined, AA concentrations as low as 0.19% vol/vol in vitro are sufficient to completely inhibit bacterial growth.
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, Jan 29, 2016
Periprosthetic infection following total knee arthroplasty is a devastating complication, which i... more Periprosthetic infection following total knee arthroplasty is a devastating complication, which is not always satisfactorily resolved by revision surgery. Arthrodesis is a salvage alternative to above-knee amputation or permanent resection arthroplasty. Fixation options include internal compression plating, external fixation, and intramedullary nails. We retrospectively reviewed twelve consecutive cases (9 males, 3 females; mean age, 67 years) of knee arthrodesis with a long intramedullary nail, performed at a single institution between 2003 and 2014. Desired outcomes were the ability to mobilize without pain, solid radiographic fusion, and the eradication of infection. Mean follow-up was 48.5 months (range, 9-120 months). Eleven patients (92 %) demonstrated stable fusion, ten patients (83 %) were ambulatory without pain, and ten patients (83 %) remained without infection at most recent follow-up. Eight patients (67 %) achieved union at an average of 12 months; three required repeat...
Tibial crest osteotomy is an established extensile knee approach. Complications include mal-union... more Tibial crest osteotomy is an established extensile knee approach. Complications include mal-union, non-union, and fixation problems.We have designed a technique aimed at reducing complications through the principles of low-energy osteotomy and suture repair. We reviewed our clinical and radiological results in 159 consecutive patients 181 osteotomies with a mean age of 66 years, and an average follow up of 22 months. Union occurred in all osteotomies (100%) at a mean period of 11 weeks. Proximal migration averaging 11.5 mm occurred in 6 osteotomies (3%). Crest fragmentation occurred in 11 osteotomies (6%), with all cases resulting in uncomplicated union. No extensor mechanism failure or complications related to the suture material occurred. We conclude that this technique results in satisfactory outcomes whilst avoiding hardware-related problems.
We describe a series of three patients who sustained patella tendon injuries in infected total kn... more We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision. The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12 to 20. Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries.
Periprosthetic knee fractures and their complications are expected to increase as the numbers of ... more Periprosthetic knee fractures and their complications are expected to increase as the numbers of knee arthroplasties continue to rise. We report our experience with revision knee arthroplasty for failure of primary fracture treatment. Five periprosthetic knee non-unions and 1 mal-union in 6 patients, with ages ranging from 65 to 83years (average 74.6years) were treated with revision total knee arthroplasty, and were followed up for 3 to 10years (average 4.5years). Union occurred in 8 to 18weeks (average 12.5weeks). All patients were ambulatory at the latest follow-up, with a range of motion averaging 84.2° (P = 0.03), and an Oxford Knee Score averaging 35 (P = 0.03). We conclude that union complications of periprosthetic knee fractures can be satisfactorily addressed with revision arthroplasty.
QUESTION 1A: Is there a role for preoperative skin cleansing with an antiseptic? Consensus: Yes. ... more QUESTION 1A: Is there a role for preoperative skin cleansing with an antiseptic? Consensus: Yes. Preoperative cleansing of the skin with chlorhexidine gluconate (CHG) should be implemented. In the presence of a sensitivity to CHG, or when it is unavailable, it is our consensus that antiseptic soap is appropriate.
Background: Tibial Tubercle Osteotomy has shown much promise in revision total knee replacement. ... more Background: Tibial Tubercle Osteotomy has shown much promise in revision total knee replacement. Methods of repair previously described include screw and wire fixation. Both methods have significant complications. Methods: This article describes suture fixation of the osteotomy using Ethibond sutures placed medially with a lateral periosteal hinge. Results: This method of fixation relies upon an adequate osteotomy segment including the entire insertion of the patella tendon. The lateral periosteal hinge is maintained and adds to the stability of the construct. A minimum of two number 5 Ethibond sutures are passed medially through drill holes to secure the osteotomy segment. No post-operative immobilisation is required. Conclusion: Ethibond sutures provide adequate fixation of the tibial tubercle osteotomy segment in revision knee arthroplasty with reduced risk of complication as compared to conventional fixation methods.
Uploads
Papers by R. Morgan-Jones