The aim of this study was to assess the results of bilateral total knee replacement (TKR) staged one week apart during one hospital admission and compare these results with those of bilateral sequential TKRs and bilateral TKRs performed in 2 separate admissions by a single surgeon using a single prosthesis. Between 5th November 1997 and 10th August 2004, 104 patients underwent bilateral LCS TKRs using the Anteroposterior glide (APG) tibial component. The patients were analysed in 3 groups. The patients in Group 1 underwent bilateral sequential TKR under the same anaesthetic. The patients in Group 2 underwent bilateral TKRs under 2 separate anaesthetics, 7 days apart, during the same admission. The patients in Group 3 underwent bilateral TKR under 2 separate admissions, essentially 2 unilateral TKRs. The patients in Group 1 had shorter operations (p< 0.0001) and shorter hospital stays (p< 0.0001). Patients in Group 2 had less blood loss (p=0.004) but were not transfused any less than the other groups. The complication rate was low and comparable in all groups. There were no in hospital or 30 day deaths in any of the groups. Those patients in Group 3 had worse AKS function scores (p=0.02) and those patients in Group 2 had a significantly better HSS score (p=0.02). There was no significant difference between the groups in terms of range of motion or the AKS Knee score. This study has confirmed a shorter operation and hospital stay when the bilateral TKRs are carried out under the same anaesthetic. These patients also bled the most postoperatively. There was little difference in terms of complications and clinical outcome at a mean follow up of 4 years. With appropriate patient selection, both same anaesthetic and same admission bilateral TKR are safe methods to treat bilateral arthritis.

Introduction: A cementless femoral implant is currently available for hip resurfacing with several theoretical advantages over cemented fixation, one of which is a potential reduction in systemic emboli. A prospective study was undertaken to evaluate the occurrence of systemic emboli using a cementless femoral component for hip resurfacing in comparison to cemented femoral fixation.

Methods: Between November 2004 and December 2005 patients scheduled for elective hip resurfacing for osteoarthritis were consented to undergo hip resurfacing using a cemented femoral component (Articular Surface Replacement or Birmingham Hip Resurfacing) or a cementless femoral component (Bi-coat Cormet Hip Resurfacing). Each case was randomised to femoral venting or no femoral venting. Intra-operative monitoring with a Transcranial Doppler device was used to identify and record systemic emboli throughout each case. Demographic and peri-operative data were collected including mental score and vital observations at day 1 and day 3, and blood loss.

Results: 8 patients (5 vented, 3 unvented) underwent cemented resurfacing and 7 patients (4 vented, 3 unvented) had cementless resurfacing. There was no difference between the two groups for age (mean 56yrs), gender, weight, or ASA status. The mean number of significant emboli (> 12dB) in the cemented group was 8.1 and in the cementless group was 1.7 (significant, p=0.009). Peri-operatively both groups were similar for vital observations, haemoglobin, mental scores and SaO₂. Venting did not influence rate of emboli. However, venting was independently associated with significantly higher drainage (mean 604mls compared to 335mls without venting, p=0.018).

Discussion: This study has shown significantly less systemic emboli occur with the use of a cementless femoral component during hip resurfacing in comparison to a cemented implant. We propose this is due to intra-osseus pressure generated when using cement. The number of emboli is unaffected by femoral venting, but more blood loss occurs after venting.

Introduction: The use of minimal incision THR is increasing. The purpose of this study is to determine the effects of a change in operative technique from a standard incision to a minimally invasive incision at primary THR on peri-operative blood loss, analgesia requirement, length of stay, and complication rate. Two consecutive groups are compared.

Materials and methods: All patients who underwent a primary THR (posterior approach) by the senior author during a 3month period before and after a change in technique from a standard to a minimal incision were identified. 202 patients were analysed: 105 standard incisions and 97 minimal incisions. A retrospective chart review was used to collect age, height, weight, BMI, diagnosis and length of stay for each patient. Estimated peri-operative blood loss in units of blood was calculated by a validated formula. Morphine usage by PCA in the first 24hours post-operatively was recorded. Complications were identified.

Results: There was no significant difference in the mean age, height, weight or BMI between the 2 groups. Predominant diagnosis was primary osteoarthritis. Mean wound length for the standard incision was 16.6cms. Mean wound length for the minimal incision was 11cms. There was no difference in length of stay, mean 5.4days. There was no difference in morphine usage by PCA in the first 24hours, mean 39.4mgs.

Average estimated peri-operative blood loss for the standard incision group was 3.45 units and for the minimal incision group was 3.05 units (statistically significant, p-value 0.039, 95%CI). One patient after minimal incision had a superficial wound infection, which responded to oral antibiotics. There was one dislocation (standard incision).

Conclusions: Peri-operative estimated blood loss was less with a minimal incision but there was no difference in length of stay or analgesia requirement. A prospective RCT is now underway to determine the clinical efficacy of minimally invasive THR.

Objective: To assess the factors which result in increased mortality following a femoral neck fracture.

Design: Patients were sequentially recruited on admission to the fracture units and followed up at 2 weeks, 3 months, 6 months and 1 year.

Setting: The fracture units of two major Belfast teaching hospitals, The Royal Victoria and Belfast City Hospital (which have since amalgamated)

Subjects: All patients over the age of 65 years between 27th October 1997 and 30th November 1998 and who were admitted to the fracture units within 28 days of having sustained a fracture.

Outcome measures: Patients were assessed by: Barthel score, mental score, home circumstances. Mobility and mortality

Results: 748 patients (male/female 153/595). Mean age 82.1 years ± s.d. 7.4 years.

The overall 1-year mortality was 31.4% (235/748) and the sex distribution (male 73/153 [47.7%] female 162/595 [27.2%]).

27/748 patients who did not undergo surgical intervention had a 1-year mortality of 85.2%.

Factors which were associated with an increased 1 year mortality were: male sex (p< 0.0005), High ASA score (p< 0.0005), low Barthel score (p< 0.0005), poor mental score (p< 0.0005), decreased mobility (p< 0.0005), increased dependency in home circumstances (p< 0.0005), increased age (p< 0.0005), increased delay to surgery (p< 0.0005) and living alone (p< 0.0005).

Marital status, fracture type and type of operative intervention had no statistical effect on mortality.

Using logistic regression male sex, high ASA score, increased age, increased delay to surgery and poor mental score all remained independently associated with an increased mortality at 1 year.

Conclusion: The majority of factors which are associated with increased mortality following a femoral neck fracture are outside our control, namely age, sex and mental score. It should however be possible to reduce surgical delay and improve the patients pre-operative medical status (ASA score). A balance has to be struck between optimisation of the patient and delaying surgery unduly. The optimal timing of surgery requires further investigation.