Introduction: The functional outcome and survivorship of knee arthroplasty in young patients remains a concern. The aim of this study is to assess patient reported outcomes of knee arthroplasty surgery in osteoarthritic patients age 55 years old or younger in a generalist setting.

Patients and methods: All patients 55 years old or younger at the time of index arthroplasty were identified from the Trent arthroplasty register. Demographic data was available for all patients. A self-administered questionnaire was mailed to patients. This questionnaire included an Oxford Knee Score along with questions relating to employment, leisure activities and the patient expectations of their surgery.

Results: 242 patients 55 years old or younger had a knee arthroplasty in the study period (male:female 1:1). 208 patients had a total knee arthroplasty. The remaining had a unicompartmental knee replacement. Mean age of patients for the total knee arthroplasty group was 51 years (range 37–55) and that for the unicompartmental group was 50 years (range 37–55). The average length of follow up for the total knee arthroplasty group was 33.3 months (range 12–57) and that for the unicom-partmental group was 29.3 months (range 16–45). The average Oxford knee score at follow up was comparable between the two groups; 31.8 (range 12–57) for the total knee arthroplasty group and 32.0 (range 13–54) for the unicompartmental group. 77% of patients in the total knee arthroplasty group and 71% of patients in the uni-compartmental group reported that the pain relief was better or just as they expected following the operation.

Conclusion: Knee arthroplasty remains a satisfactory procedure in young patients under the age of 55 years. There is no significant difference in Oxford knee scores between patients that have total knee replacement or unicompart-mental knee replacement. Pain relief is better or just as expected in the majority of patients in both groups.

Background: Many patients with hip fractures have multiple medical problems that require attention. Pre-operative specialist interventions can often cause unnecessary delay. The aims of this study were to quantify the proportion of hip fracture patients that have an echocardiogram, to find out who and why the investigation was requested and to quantify the delay and its consequences.

Methods: Retrospective review of all patients over a 9 month period that were admitted to hospital with a diagnosed hip fracture and had an echocardiogram as part of their pre-operative assessment.

Results: 31 patients fulfilled the inclusion criteria. 23 sets of notes were reviewed. The majority of echocardiograms 17/23 were requested by orthopaedic SHOs without anaesthetic request. The reason for requesting the echocardiogram was the finding of a murmur on clinical examination.

The average delay from admission to having an operation for patients who had an echocardiogram was 6.7 days (mode 5days). Mean delay to patients having the echocardiogram was 3.2 days (mode 2 days) and the delay to theatre after the echocardiogram was 3.5 days (mode 1 day). 15/23 patients had adverse effects. All but one patient had a routine uncomplicated anaesthetic. Conclusion: 6–7% of hip fractures have an echocardiogram. Junior members of the orthopaedic team request the majority of echocardiograms without anaesthetic input. Requesting an echocardiogram causes a delay from admission to theatre of approximately 1 week. Delay is associated with adverse effects, which may have fatal consequences for the patient.

Background: The majority of extracapsular proximal femoral fractures are treated with a sliding hip screw. The barrel of the plate can slide over the shaft of the screw in two modes; keyed (locked) or unkeyed (unlocked). The purpose of the study was to determine whether there is a difference in outcome following fixation using a sliding hip screw in the locked and unlocked modes.

Methods: A prospective randomised controlled trial of patients requiring a sliding hip screw for a proximal femoral fracture. Patients were randomised to receive a sliding hip screw either in the locked or unlocked mode. 20 patients were randomised to each group. Patients were assessed clinically and radiologically post-operatively and at three months following discharge from hospital. Screw slide and fixation failure were used as primary outcomes. A Visual analogue scoring system (VAS) was used to assess pain.

Results: A total of 40 patients were recruited in this study. The mean age of patients in the locked group was 74.05 years (range 55–90) and 78.0 years (range 65–97) in the unlocked group. There was one case of fixation failure in the locked group compared to two in the unlocked group. The mean screw slide was 10.98mm (range 1.04–37.62) in the locked group and 12.94mm (range 1.91–20.82) in the unlocked group. The pain score according to the VAS improved over the three months. There was no significant difference in pain score between the two groups.

Conclusion: When comparing screw slide, fixation failure and pain, the results show there is no significant difference between using the sliding hip screw in the locked and unlocked mode.

Introduction: With an ever-increasing elderly population the rise in primary total hip replacement is inevitable. This translates into a comparative rise in revision hip surgery. We performed an observational study to determine current revision hip surgical practices in one UK region.

Methods: We utilized a regional hip register (Trent Arthroplasty Audit Group (TAAG)) to review current revision hip surgical practice in our region. 136 surgeons in 21 different hospitals, covering a population of 6.2 million, contribute to the register. We analysed completed data forms to produce the following results.

Results: 875 revision THRs performed between 2000 and 2002 were identified. 54% were female, with a mean age of 70 (range 26–97). 45 different femoral stems requiring revision were identified. Reasons for revision were aseptic loosening of both components (23%), cup alone (24%), stem alone (17%), infection (14%), recurrent dislocation (10%), periprosthetic fracture (5%) and acetabular erosion (3%). Over 25 different femoral stems and over 30 different acetabular components were utilised by surgeons. In 70% of cases the femoral and acetabular components were made by different manufacturers. Bone graft was used in approximately 50% of cases. 90% of centres contributing to TAAG perform revision hip surgery. 24% of all revision THRs were performed by surgeons performing 5 or less per year. Only 40% of revision THRs were performed by ‘revision surgeons’ performing > 20 per year.

Conclusions: It is evident the majority of centres, both teaching and DGH, in our region regularly perform revision hip surgery, with up to a quarter performed by non-revision specialists. With increasing numbers of prostheses available, high numbers of component mismatch use, and the inevitable increase in future need for revision hip surgery, is the occasional revision surgeon compromising patient care? Will this have future medico-legal consequences?

Background: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

Method: 28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MES’s) were recorded during the operative procedure.

Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MES’s had undergone a cemented hemiarthroplasty the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MES’s after reaming and cementing. MES’s in the patients that had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.

Deep venous thrombosis (DVT) and clinical outcome measurements in a series of 610 patients who did not receive routine chemical thromboprophylaxis for lower limb arthroplasty were studied. Patients who had undergone primary total hip or knee replacement under the care of two orthopaedic consultants were identified from the Trent Arthroplasty Database. Surgery was performed between 1992 and 1999 in one hospital only. Venography was undertaken on the seventh to tenth postoperative day. Patients with proximal thrombosis were anti-coagulated with warfarin as per protocol. Venogram reports were available for 81% of cases.

One year following surgery a standard postal questionnaire was sent to all patients. A response rate of 88% was achieved. Data was captured with respect to residual pain, ability to walk and the overall satisfaction with joint replacement.

DVT following total hip (THR) or knee replacement (TKR) in patients who did not receive routine chemical thromboprophylaxis was common (46. 4%) in line with other studies.

Knee surgery was associated with a high prevalence of thrombosis (57. 6%) compared to hip replacement although only one fifth of DVTs were found to extend into a proximal vein. Approximately half (44. 2%) of all THR associated thrombus was above knee DVT. Questionnaire responses evaluating clinical outcome and satisfaction were correlated to venographic results and analysed using an SPSS statistical package. Using Chi-squared analysis no statistically significant differences were found between deep venous thrombosis and patient-perceived pain (p=0. 12), mobility (p=0. 07) or overall satisfaction (p=0. 23). It is generally assumed that chemical thromboprophylaxis will diminish DVT related complications such as post-phlebitic limb syndrome. Despite a high prevalence of thrombosis in patients who did not receive pharmacological agents for prophylaxis, this study did not demonstrate an adverse outcome on pain, function or patient satisfaction. Morbidity as a result of DVT needs to be studied further before the role of chemical thromboprophylaxis can be determined.

The proportion of very elderly people within the general population is steadily increasing.

These people, who often have coexisting medical problems and a limited life expectancy, may pose a dilemma for Orthopaedic Surgeons when referred for elective Orthopaedic procedures. The purpose of this study is to review the outcome of primary hip and knee arthroplasty in patients aged 90, and over, who are registered with the Trent Regional Arthroplasty Database.

Between 1990 and 2000, prospective data was collected on patients aged 90, and over, undergoing primary total hip and knee arthroplasty. Data collection was carried out on behalf of the Trent Regional Arthroplasty Audit Group. The present living status of these patients was confirmed using patient administrations systems of the hospitals involved.

Missing data was obtained from the Office for National Statistics. Those patients alive at one year were sent a simple satisfaction questionnaire regarding their operation.

144 patients underwent 149 hip or knee arthroplasty procedures over this eleven year period. The group comprised 122 (85%) females and 27 (15%) males. There were 93 (62%) total hip replacements and 56 (38%) total knee replacements. Ostcoarthritis was the predominant reason for surgery. There was only one intra-operative complication, comprising a fractured femur during a total hip replacement. 78 patients have died since their surgery. The crude mortality rate at one year was 11. 5%. The median survival was 34 months. 51% of the patients returned satisfaction questionnaires one year after the operation. From this group the satisfaction rates for hip and knee arthroplasty were 93. 6% and 92. 6% retrospectively.

With suitable pre-operative assessment, primary total hip and knee arthroplasty can be a successful operation with a high satisfaction rate. This is an age group with a high mortality regardless of surgery, and age alone should not be a determining factor in deciding whether a patient will benefit from primary hip or knee arthroplasty.

To study the admissions to a busy trauma unit on a day by day basis over a one year period, and to look for any correlation with local weather variation or temporal factors (day of the week, week-ends/school holidays etc. )

Admissions data for the Trauma Unit at the Leicester Royal Infirmary was collected for the calendar year of 1998. On a day-by-day basis, admissions were split into four groups: all admissions, adult admissions, admissions for fractured neck of femur (NOF) and paediatric admissions. Weather information for the local area was obtained from the Met. Office.

Details of school holidays were obtained from the local Education Department.

A number of climatic and temporal variables were examined using Poisson regression analysis for their potential importance in explaining day-to-day variation in admission rates for the four groups.

For adult and NOF admissions, none of the weather factors appeared to explain variation in incidence. For total and paediatric admissions, a number of factors appear important, with the daily maximum temperature being the single most important using univariate analysis.

Total trauma admissions increase on hot days; this is mainly due to an increase in paediatric admissions. Interestingly, there are more adult admissions in the early part of the week than later in the week. The implication is that a hot Monday will be a very busy day. The reasons for this will be explored.

Purpose: To determine the current arthroplasty practice in osteoarthritic patients aged 55yrs or less for the population registered on the Trent & Wales Arthroplasty Database and stimulate debate. Is there a ‘gold standard’? If there is what is it ?

Method: The Trent Arthroplasty Audit Group collects prospective data on all hip arthroplasty surgery performed in Trent Region & North & West Wales (population 6.2 million). In 2000/2001 9.4% of the primary T.H.Rs and 14.1% of the revision T.H.Rs were aged 55yrs or less. We analysed the database to produce the following results.

Results: In 2000/01 385 primary T.H.Rs were performed on patients aged< 55yrs. 52% of the patients were male, the mean age at surgery was 48.3 yrs (Range 30–55yrs). 12% of the patients had a metal on metal hip resurfacing implant. In 39% both the femoral and acetabular components were uncemented. 14% had a hybrid combination. In 36% of cases the femoral and acetabular components were made by different manufacturers.

The bearing surfaces chosen were: metal / metal in 13%, metal on poly in 56%, ceramic on poly in 28% (Zirconia in 7.4%) and ceramic on ceramic in 3%. Low viscosity cement was used with 28% of femoral components and 19% of acetabular components. The predominant femoral head size was 28 mm.(49%) (22mm in 23%).

Conclusion: Surgeons strive to use up-to-date technology in young patients in an attempt to prolong the life of their hip replacement. At the present time we don’t appear to have a clear picture as to what is the ‘gold standard’ for young patients. How much evidence do we need before implanting a new implant or combination?