title: Primary total knee replacement: a comparison of a nationally agreed guide to best practice and current surgical technique as determined by the North West Regional Arthroplasty Register.
abstract: BACKGROUND
  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 Association for Surgery of the Knee (BASK) to provide a basis for regional and national auditable standards: we have compared practice in the North West of England to this document to ascertain adherence to this guide to best practice.
  
  
  METHODS
  A direct comparison of data held on the North West Hip Arthroplasty Register for 2001/2002 and BASK/BOA guidelines was performed. 86 surgeons from 26 hospitals were included in the study.
  
  
  RESULTS
  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. 42.2% of respondents routinely used exhaust suits and 68.1% of respondents routinely used impermeable disposable gowns. All surgeons use 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. 93.7% of surgeons routinely use antibiotic-loaded cement. The PFC and Kinemax prostheses were the most commonly used prostheses. Interestingly, 97.7% of all first-choice implants were cemented. Only 2 surgeons used uncemented total knee replacement. 69.8% of surgeons used a posterior cruciate retaining design. A midline longitudinal skin incision is used by 87.2% of surgeons, a medial longitudinal skin incision by 7.0% and a lateral longitudinal skin incision by 5.8% of surgeons. A medial parapatellar capsular incision is preferred by 91.9% with the remainder using mid vastus or trivector retaining capsulotomy. Closure of capsulotomies is performed in flexion by 65.1% and in extension by 34.9%. In patients with osteoarthritis, 38.4% routinely resurfaced the patella, 34.9% never resurfaced the patella and 26.7% selectively resurfaced. This was in direct contrast to practice for patients with rheumatoid arthritis in whom 66.3% routinely resurfaced the patella, 22.1% never resurfaced the patella and 11.6% selectively resurfaced.
  
  
  CONCLUSIONS
  This study has demonstrated variation of practice in hip arthroplasty across the North West region and significant divergence from the BASK/BOA statement of best practice. The introduction of a properly funded national arthroplasty register will surely help to clarify the effect of such diverse practice on patient outcome.
authors.affiliation: The Centre for Hip Surgery, Wrightington Hospital, Wigan, UK. hammymalik@hotmail.com
authors.forename: M H A
authors.initials: MH
authors.lastname: Malik
authors.forename: A
authors.initials: A
authors.lastname: Chougle
authors.forename: N
authors.initials: N
authors.lastname: Pradhan
authors.forename: A K
authors.initials: AK
authors.lastname: Gambhir
authors.forename: M L
authors.initials: ML
authors.lastname: Porter
mesh_terms: D019072:Antibiotic Prophylaxis / Q000706:statistics & numerical data; D019645:Arthroplasty, Replacement, Knee / Q000379:methods / Q000592:standards*; D004739:England; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006302:Health Services Research; D006801:Humans; D007720:Knee Prosthesis; D009873:Operating Rooms; D011182:Postoperative Care / Q000379:methods; D017410:Practice Guidelines as Topic; D011364:Professional Practice / Q000706:statistics & numerical data*; D012042:Registries; D011795:Surveys and Questionnaires; D013923:Thromboembolism / Q000517:prevention & control; D006113:United Kingdom