Introduction: Hypothesis: Patients undergoing operations at the end of the week are disadvantaged by the lack of weekend physiotherapy. Aim: To test the hypothesis by review of a single surgeon series of patients identifying factors affecting the post-operative length of stay

Methods: A cohort of patients with OA undergoing elective primary joint replacement was identified. Data was collected for demographics, procedures undertaken and length of stay.

Results: 42 patients were included in the cohort. There were 23 hip and 19 knee replacements with an average age of 73.47 years. Multivariate analysis of the data was performed to ensure that the age, pathology, ASA and days of the week were equally represented. Further analysis revealed that the main factor contributing to length of stay was the age of the patient (5.13 days if age< 75 vs. 6.33 days if olderthan 75 years). Patients having surgery at the end of the week actually had a reduced length of stay compared to those at the start of the week (5.27 vs. 6.22 days).

Discussion: The day of surgery does have effect on the length of stay post op. The widespread assumption that weekend physio to mobilise patients early post op may not be well founded. It is more likely that targetting patients to encourage discharge would be a more effective use of resource.

Aim: To determine if it is possible to predict the pattern of socket failure from the first post-operative x-rays.

Methods: A retrospective review was performed of patients undergoing revision hip surgery for aseptic socket loosening. An assessment was made of the pattern of failure and socket migration. Operative details of bone defects and reconstructions required were noted.

Results: 55 patients were identified with an average age of 46.2 years at primary surgery. The average socket survival was 16.14 years. There was no association between the patient’s age or original diagnosis and the duration of socket survival.

Supero-medial migration was seen in 27 (49%) of cases, demarcation without migration was seen in 18 cases (33%) and supero-lateral migration was seen in 7 (13%) cases. There were 2 (4%) socket fatigue fractures due to wear. There was 1 (2%) patient with a worn socket and no loosening.

Reconstruction was achieved by impaction bone grafting alone in 25 cases, IBG and a block allograft in 9 cases, cement alone in 8 cases and IBG with a rim mesh in 4 cases.

In cases where the supero-lateral margin of the socket was covered by host bone, failure always occurred by demarcation alone or in association with supero-medial migration. Rim defects significant enough to require reconstruction were seen in only 4 of these 45 patients (9%). Failure by supero-lateral migration was only seen in the cases of DDH where the socket was left uncovered or where the socket had fractured.

Conclusions: In this young age group series cemented acetabular components performed well, failed predictably and were relatively straightforward to reconstruct.

The pattern of socket failure can be reliably predicted from the original post-operative x-rays. Care should be taken to ensure adequate supero-lateral coverage in order that demarcation and migration leave an intact rim for reconstruction.

Introduction: Recurrent Instability of the hip remains a difficult problem to treat successfully. The Posterior Lip Augmentation Device (PLAD) is a useful option where there is no gross mal-orientation of the components.

Methods: A retrospective single surgeon review was performed to identify patients who had undergone application of a PLAD to treat recurrent instability. Patients with less than 12 months follow up were excluded.

Results: 14 patients were identified with an average age of 75.5 years (Range 59 – 90 years). There were 7 cases of trochanteric non-union as a result of previous surgery. The mean follow up was 26 months (Range 13 – 41 months). In 13 patients there have been no further instances of dislocation. 1 patient went on to dislocate again and has now undergone a socket revision.

Conclusion: Application of the Posterior Lip Augmentation Device is a well tolerated procedure with very favourable success rates (93%). Given the limited morbidity and short operating time associated with this surgical option it provides a predictable outcome in cases where the original components are well orientated and securely fixed.

Introduction: Revision hip arthroplasty places a significant burden on hospital resources. Huge pressure is being placed on the orthopaedic community to alter practices with respect to implant selection and bearing surfaces in order to try to reduce the likelihood of revision due to aseptic socket loosening. To date there is little clinical evidence to support these changes.

Aim: To review the case mix requiring revision surgery at a specialist arthroplasty unit in order to identify the common reasons for failure of primary arthroplasties.

Methods: A retrospective single surgeon review was performed to identify patients who had undergone revision hip surgery over the study period. The reasons for revision were identified for all cases. Particular attention was paid to the cases with aseptic socket loosening to determine the time to revision for these cases.

Results: 176 revision procedures were performed between October 2001 and May 2005. In 74 (42%) cases aseptic socket loosening was identified (average socket survival 15.4 years). In 16 cases this was the sole cause for revision. In 58 cases the femoral component was also loose. 102 (58%) cases were performed for other reasons. Dislocation was the cause in 14%, femoral component loosening in 20%, infection in 18% and fracture in 6%. Aseptic loosening of cemented sockets less than 10 years old was only seen in 7 (4%) cases.

Conclusions: Aseptic loosening of cemented sockets less than 10 years old was the least common cause of revision in this series. Cemented polyethylene acetabular components continue to provide a satisfactory bearing surface on the acetabular side of total hip arthroplasties. We recommend caution when interpreting the information provided with new products with respect to the benefits of different fixation and bearing surfaces for the majority of patients.

To review the outcome of patients with deep infection using a new 2-stage revision technique.

A management plan consisting of initial debridement, insertion of antibiotic spacers and 2 weeks of intravenous antibiotics is currently used. No further antibiotics are given systemically. If blood tests are satisfactory at 12 weeks, reimplantation occurs. Patients are encouraged to partially weight-bear and perform a range of motion exercises with their spacers in place. The necessary data has been prospectively collected to identify predictors of success.

Thirty four patients have been identified and fully followed up for more than 1 year. 27 patients have over 2 years of follow-up. When looking at all of the patients we have achieved an 82% success rate. For patients whose only previous major surgery was their arthroplasty this rises to 90%. Where multiple surgeries have been undertaken this falls to 73%. All of the peri-operative investigations have been reviewed and whilst they have a good negative predictive value they are not specific enough to alter practice.

Conclusions: Short courses of parenteral treatment can produce comparable results to previously- published series when treating deep infection after knee replacement. There seems to be a failure rate that is difficult to avoid associated with chronic, multiple revision cases.

Background. Just under 2% of the joint infection work performed over the last 10 years in our institution has involved organisms found in the oropharynx. The issue of antibiotic prophylaxis for dental work in the presence of a joint prosthesis is controversial. However, advanced dental sepsis requires detection and treatment prior to joint replacement.

Methods. Patients from whom non B-haemolytic streptococcal were recovered from revisions of prosthetic joints over the period 1993–2003 were retrospectively reviewed for predisposing factors.

Results. 9 patients had viridans streptococcal infection detected and confirmed by histology and culture at excision arthroplasty. There were 5 total hip joints, 3 knee arthroplasties and 1 shoulder affected. No patient had a history of endocarditis. Two of the patients had previously had multiple revisions. Mean interval in these patients since last surgery was 7.6 years. All patients underwent 2 stage revision procedures. All patients required multiple dental extractions in the interval between 1st and 2nd stage surgery.

On reviewing the patients’ histories further: One patient had reported a broken tooth reported at the time of surgery and been given reassurancethat it was safe to proceed. One patient had an overt dental abscess ongoing for 15 years and one patient had an occult dental abscess revealed on radiology. Two other patients had extensive dental caries with blackened stumps as teeth. Follow-up after antibiotic treatment and revision arthroplasty is limited in these cases but results appear satisfactory at up to five years.

Conclusion. Poor dental care is associated with an increased risk of arthroplasty infection. Looking in the mouth should be a routine part of pre-op assessment prior to primary joint replacement, just as it would be in a cardiac surgery unit. Patients referred from other centres for revision arthroplasty should receive a dental examination if excision arthroplasty cultures yield viridans streptococci.

Introduction: Femoral offset plays an important part in the biomechanics of the hip with inaccurate balancing at the time of arthroplasty leading to abductor weakness, leg length discrepancies and altered wear characteristics.

Aim: To look at the degree of external rotation of the leg at the time of pre-operative x-rays and to assess the effect of this on templating for femoral offset.

Methods: A radiological review of a cohort of patients attending for hip arthroplasty with unilateral osteoarthritis.

Results: Externally rotated posturing of the affected leg is common amongst patients with osteoarthritis attending for hip arthroplasty. The effect of this change in the positioning of the femoral neck is to create an apparent reduction in the offset of the femoral shaft. This will lead to underestimation of the correct offset for the chosen prosthesis. In over 50% of cases templating would have been incorrect.

Conclusions: When templating prior to hip arthroplasty surgery an assessment of the profile of the lesser trochanter will give an impression of the leg position. If this is externally rotated it should be presumed that the offset will be larger than the measured value. If the other hip is in a better rotational position this should be used for assessment.

Introduction: The very nature of revision hip arthroplasty is such that blood loss is to be expected. Anticipation of this problem, accurate assessment of the losses and prompt replacement of losses are the mainstay of intra-operative care.

Aim: We present a user friendly system for communication of intra-operative blood loss

Principles: The classic car heritage of this country provides a wealth of vehicles traditionally associated with given volumes of engine. As such this easy scale can be used throughout the procedure to allow the anaesthetist to convey a readily recognizable figure to the operating surgeon.

The classification:

Fiat Cinquecento 500mls

Conclusion: We feel that this new system conveys readily recognisable symbols to a quantum that may otherwise pass unnoticed by the surgeon.

Aim: A retrospective review of the triple pelvic osteotomies performed between 1988 and 2002 identifying the factors that may predict a favourable outcome from surgery.

Method: A case note and x-ray review identifying various parameters that influence outcome.

Results: 30 osteotomies in 26 patients have been studied. 3male and 27 female patients have been identified. All patients were symptomatic prior to surgery complaining of pain and reduced exercise tolerance. Following surgery 21 patients were satisfied with their outcome and 9 patients had poor results.

The average age of patients with a good outcome was 20.9 years. The average age of patients with a poor outcome was 30.9 years.

There was no correlation between the correction of either the Sharp angle or the centre-edge angle and outcome. Sphericity of the head was unrelated to outcome. Obesity was associated with a poorer outcome in older patients.

Conclusion: Triple pelvic osteotomy provides a reliable method of improving symptoms in younger patients with dysplastic hips. An increased rate of failure should be expected in patients over thirty years of age.

Introduction: Template use prior to hip arthroplasty is a valuable form of pre-operative planning. The femoral neck anteversion may influence the interpretation of the femoral off-set on plain x-rays

Method: The femoral neck anteversion of a series of adult patients with developmental hip dysplasia has been assessed using CT guided measurement. Using this data and more normal ranges of anteversion we have been able to estimate the effect of anteversion on perceived off-set.

Results: Femoral neck anteversion significantly effects the perceived offset at angles of greater than 20 degrees. The average femoral neck anteversion in our series of patients with hip dysplasia was 22 degrees. With a perceived off-set of 40mm on an AP x-ray the actual offset becomes 44mm in a patient when the patient has 25 degrees of anteversion.

Conclusion: Femoral neck anteversion is an important factor when considering the appearance of plain hip x-rays. Recognition of this factor may improve the ability of the operating surgeon to assess the correct components pre-operatively.

Introduction: There are approximately 50000 hip and knee arthroplasties performed in the UK every year. With this increasing number the prevalence of periprosthetic fractures is also rising. These are often challenging problems with increased morbidity and mortality. The use of cortical strut allografts in periprosthetic fractures was first reported in the early 90’s with favourable results.The aim of this study was to assess the radiological outcome of cortical strut allografts used as the treatment for periprosthetic fractures of the femur in patients presenting to our institution.

Patients & Methods: 17 patients with who had received strut allografts as part of their treatment for a periprosthetic fracture of the femur were identified. 13 fractures were around a total hip replacement and 4 around other femoral implants (2 long stemmed TKR’s and 2 fracture fixation devices).

We undertook a radiological evaluation of this technique. We assessed fracture union and strut allograft incorporation using the radiological criteria of Emerson et al. The procedure was deemed a success if the fracture had united, with evidence of graft incorporation with a stable implant. We also undertook a notes review identifying any risk factors and any previous surgery.

Results: Two patients died in the early post-operative period. 15 patients were available for analysis. The average length of radiographic review was 16 months. 11/15 procedures (73%) were deemed a success. All these showed evidence of graft incorporation which was time dependent. There were four failures. In one patient the struts fractured at two months. There were three cases of deep sepsis, this required amputation in one and excision arthroplasty in two.

Conclusion: Cortical strut allografts are a good technique for the management of periprosthetic fractures of the femur. As well as providing initial support they also become incorporated which improves the host bone stock.

The purpose of this study was to determine arthroscopically the pathology following anterior shoulder dislocation and assess visually whether rotation of the arm affected the reduction of the capsulolabral complex in cases where this was detached.

Over a sixteen month period from December 2000 to March 2002 we have arthroscoped and followed up prospectively a cohort of thirty patients. All patients were immobilised in a sling for four weeks and rehabilitated in a similar fashion with physiotherapy. The average age of the patients was 31 years and all patients were arthroscoped within six weeks of injury. The Hill Sachs lesion and capsulolabral complex injury were the most common pathology and were seen in two thirds of the patients. In the remaining group capsular tears and stretching were the most frequent injuries seen.

Injuries to the capsulolabral complex were seen in 22 patients. In seventeen of these the capsulolabral complex was still mobile and the time to arthroscopy averaged 10.3 days (Range 0–25). In the remaining five patients the labrum had healed in a malreduced position. The average time to arthroscopy in these patients was 30.8 days (Range 19–42).

In the patients where the capsulolabral complex had not reattached 14/17 (82%) patients demonstrated a better reduction of the labrum onto the glenoid with the arm in external rotation.

Based on these findings we conclude that:

The traditional use of a sling with the arm internally rotated may contribute to the capsulolabral complex healing in a malreduced position. This may be a contributory factor to the high redislocation rates found in young adults. Splinting the arm in a position of external rotation for four weeks may allow better reduction of the capsulolabral complex onto the glenoid.