Introduction: The Opera Acetabular cup (Smith and nephew) was designed in North Manchester General and has been in use since 1997. The initial results were with multiple surgeons, different approaches and 2 different stems. We report the early results of the opera cup in primary hip replacements using the C-Stem.

Methods: This is a prospective radiological follow up of patients operated on between June 2000 and November 2004. 202 consecutive primary hip replacements were carried out using the Opera cup and a standard C-stem. All operations were performed by a single surgeon using the posterior approach. Initial and annual x-rays were studied and the following measurements taken: cup angle; radiolucent lines in the bone-cement interface of the acetabulum; heterotopic ossification; radiolucent lines or osteolysis in the femoral component and stem orientation.

Results: Full data is available in 166 hips performed on 149 patients. Average follow up is 37 months (12–65). 84 patients were female and 65 male. There were 56 left hip replacements, 76 right hip replacements and 17 were bilateral. 162 hips had an elite head whereas 4 had a ceramic head. Average cup angle was 44.6 degrees. 20 Cups had 0.5mm lucency in zone 1 of the acetabulum and 1 cup had 1mm lucency in zone 1. None were progressive. 14 patients had grade 1 heterotopic ossification 3 patients had grade 2. 1 stem was in valgus and 13 stems were in varus.

Complications were 1 calcar fracture and 1 greater trochanter fracture (both of which required circlage wires). There was also 1 temporary femoral nerve palsy which resolved in 3 months. There were no fatal PE’s, deep infections or dislocations. No hips have required revision.

Discussion: We conclude that in the short term the Opera cup is performing to the standard required by NICE.

This is a prospective study to determine if we could identify patients who may benefit from preoperative catheterisation in lower limb arthroplasty.

211 consecutive patients undergoing total hip and knee arthroplasty were recruited. There were 131 female (62%) and 80 male (32%), the mean age (+−1 S.D.) was 68+−12 years old. Patients’ demographic details and pre-operative urinary symptoms were recorded. Previous urological surgery and past history of urinary catherisation were also documented. The anaesthetist who was blinded from the study selected the type of anaesthesia and the post-operative analgesia regime. All patients were required to produce mid-stream urine sample before surgery and at post-operation. Urine tract infection was confirmed on a positive microbiological culture. Regression analysis was used to assess various co-variables to identify the high-risk groups.

35 female (56%) and 27 male (44%) were catheterised, the mean age (+−1 S.D.) was 72+/−14 years old. The frequency of catheterisation was unrelated to the surgical procedure, the type of anaesthesia or the postoperative pain control regime. Age over 65 years old and nocturia were significant indicators for urinary catheterisation (p< 0.05). Patients with urinary incontinence and nocturia were strong determinant for urinary catheterisation (p< 0.03). Males over the age 65 years with a past history of urinary catheterisation (p=0.037) were more likely to be catheterised than females of the same group (p=0.947). This has become more evidential if patients have coexisting urinary incontinence and nocturia (p=0.005). Females over the age of 65 years with urinary incontinence were also significant (p=0.013).

The sensitivity for urinary catheterisation in patients over the age of 65 years with previous history of catheterisation, urinary incontinence or nocturia was 89.7%. This group of patients would benefit from pre-operative urinary catheterisation.

To assess the cost involved and whether orthopaedic patients with Methicillin-resistant Staphylcoccus aureus (MRSA) infections were being managed according to national guidelines, retrospective survey of all MRSA infections over a 26 months period was performed. Demographic details and risk factors were identified. Infection control measures were compared with national guidelines. Total length of hospital stays, treatments received and cost were noted.

In total, 78 patients were diagnosed with a MRSA infection (31 male and 47 female) with a mean age 66.4 years +/− 20.8 SD. MRSA infections occurred in 75 (97%) trauma patients and in 2 (3%) elective patients. MRSA infections were isolated from wounds in 62 patients, others sites include sputum, blood, urine and skin colonization. The average time of diagnosis after admission was 20.6 days +/− 16.6 SD. Major risk factors were internal fixation of fractures (97%), previous antibiotics (97%), nursing home residents and hospital transfers (50%). Normal national guidelines were followed in 86% of the cases. Antibiotics were used in 67 patients after microbiological confirmation; this additional cost exceeded £19,000. The mean hospital stay was 50.7 days and the cost of hospitalization per patients exceeded £19,700 (£388.60 per day). Incidence of MRSA infection in trauma and elective patients were 2.4% and 0.1% respectively. Infection control policies were strictly followed in 86% of the cases. Long hospitalization and antibiotics were a significant risk factor for developing MRSA infections. Considering the low incidence of MRSA infection in elective surgery, segregation of trauma and elective patients is an important measure in reducing the incidence and cost of MRSA infections. Substantial saving can be achieved with firmer antibiotics policies.

Do patients’ recollections of disease severity following joint replacement surgery accurately reflect their pre-operative disability? Oxford Knee score questionnaires were sent to 100 patients who had undergone primary knee replacement surgery between January 1998 and July 2000.They were asked to complete these in a manner reflecting their pre-operative disability. The results were then compared with actual scores completed by the same group of patients prior to their surgery. The response rate was 78%.The mean pre-operative score was 45 compared to the recall score of 46.9. The difference was not significant (p=0.77).We believe that recall of disability using a simple knee score is a reliable method of assessing pre-operative disability.

There is a legal and ethical obligation to gain informed consent before treatment commences. A number of bodies have issued guidelines for obtaining consent and these include the Department of Health, the GMC, The Royal College Surgeons of England, and the B.O.A. For a patient to give their informed consent to surgery they must receive sufficient information about their illness, proposed treatment and its prognosis. There are no specific guidelines regarding joint replacement. With this in mind a retrospective case note study was undertaken involving 100 patients who had undergone a hip replacement. Noting the documented discussion at all stages of patient contact.Fifty percent of patients had been seen and listed in the Outpatients by a Consultant, 25% were discussed with the Consultant responsible and the remainder were listed without Consultant input. In only 33 % of cases were any specific risks recorded. This had fallen to 4% on their visit to pre operative assessment clinic. All the consent forms were completed at the time of admission for surgery. Forty percent of these on the day of surgery. The majority were completed by SHOs (58%), while only 4% were completed by consultants. None of the forms noted the lead surgeon. All the consent forms noted some frequently occurring risks. However there was a large variance in the details recorded. The study highlights that the majority of complications are only documented on the consent form, with little note of the dialogue leading up to it. It is also apparent that there is no agreement as to what represents a significant or frequent complication.

This review raises a number of important issues. There needs to be a national standardisation of the process of consent. We propose the introduction of a specific consent form for hip replacements that provide improved documentation of the standardised risks involved. This should also include guidelines regarding prosthesis choice, surgical approach and the extent of trainee involvement. In addition we would also suggest there is a need to improve sequential documented discussion up to the point of surgery and introduce specific training for juniors carrying out consent.

Introduction & aims: Quadriceps muscle wasting is common in patients with osteoarthritis (OA) of the hip and knee. Previous studies,using ultrasound and performing biopsies, have demonstrated quadriceps muscle fibre atrophy. Thigh girth measurements are quoted in textbooks as a means of quantitatively assessing muscle bulk. This study has looked at these measurements in patients with hip and knee OA to see if these measurements are useful.

Method: 87 patients (mean age 62, range 36–87) with a diagnosis of OA were seen in the pre-assessment clinic. 47 were awaiting total hip replacement (THR) and 40 were awaiting total knee replacement (TKR).All were awaiting primary arthroplasty and had not had previous joint surgery. Thigh girth measurements were taken at 2 points corresponding with one-third and two-thirds of the length between the anterior superior iliac spine and the tibial tuberosity. These measurements were taken for both thighs. The observed differences were analysed with normal probability plots and paired Student’s t-tests.

Results: No significant difference in thigh girth could be detected in patients awaiting total knee replacement. Girth was significantly reduced in the thigh on the side of planned THR. This difference was apparent when measured both proximally and distally.

Conclusion: Measurements of thigh girth were not useful indicators of quadriceps wasting in patients awaiting TKR. Patients awaiting THR should have thigh girth measured, those with reduced thigh girth on the side of planned arthroplasty may have quadriceps atrophy and can then be referred for physiotherapy prior to surgery.

Aims: To investigate whether blood transfusion practice in primary total knee replacement (TKR) was being managed appropriately, and to assess the cost effectiveness of pre-operative autologous donation (PAD). Methods: A retrospective survey of blood transfusion practice was conducted for all TKR. The unit has an established PAD service with over 60% uptake for suitable candidates. An analysis of all pre-operative and post-operative haemoglobin concentrations (Hb) was performed. Using Hb concentration of 8 g/dl or 9 g/dl as the transfusion criteria, the total units of blood used, saved or discarded was calculated. Results: 174 TKR were performed, 84 (48%) patients were transfused. 52 patients (117 units) received allogenic blood, 35 patients (61 units) received PAD blood, 8 patients received both. 60 units (50%) of PAD were discarded. Using a level of Hb of 8 g/dl, 46 patients (96 units) would have received allogenic blood, 30 patients (51 units) would have received PAD blood and 7 patients both. 70 units (58%) of PAD would have been discarded. Using a level of Hb of 9 g/dl, 35 patients (69 units) would have received allogenic blood, 22 patients (36 units) would have received PAD blood and 6 patients both. 85 units (70%) of PAD would have been discarded. If the transfusion threshold used were < 8 g/dl and < 9 g/dl, the potential saving was estimated at approximately £9578 and £6884 respectively. Conclusions: PAD service is considerably more expensive than allogenic blood. With high percentages of PAD being discarded, the service is not cost effective. Substantial saving can be achieved with a þrmer transfusion policy for post-operative patients.

Aim: The aim of this research was to assess the difference in the observed tibiofemoral axis between long leg and short AP films of the knee.

Method: 20 patients who were undergoing primary total knee replacement, and had had no previous surgery on the affected limb were x-rayed using the a long leg cassette to include both the hip and ankle joints. A special screen was constructed to obscure all the x-ray except for a field, the size of a standard AP x-ray of the knee. The tibiofemoral angle was measured by two independent observers first on the short film and then on the long leg film.

Results: Our results have shown that the short leg film consistently overestimates the true tibiofemoral angle. Intraobserver correlation is also better when comparing the long leg film rather than the short film.

Conclusion: Measurement of the tibiofemoral or anatomical axis of the knee is best performed using long leg films, as this appears to give more consistent and reproducible results.

Cross match practice for patients with femoral neck fractures continue to cause concern due to a failure of compliance to the existing protocols. We addressed this issue by conducting a number of studies over three years and we report the summation of the studies and demonstrate the reasons for the poor compliance. We provide a simple and effective protocol that has helped reduce preoperative cross matching of femoral neck fractures from 71% to 16.7% two years after its introduction.

Study 1

Retrospective review of the cross-match practice for 240 femoral neck fractures and reviewed the changes in pre-operative and post-operative haemoglobin levels and association with surgical procedure.

Study 2.

Postal questionnaire of 129 anaesthetic and orthopaedic trainees assessing the perceived cross-match requirements of patients with femoral neck fractures based on preoperative haemoglobin values between 8–13g/dl. In addition reviewed the source of trainees perceptions and practice

Study 3

Review of the efficiency of the cross-match protocol two years after its introduction Results

Study 1

71% patients with femoral neck fractures were cross-matched at admission but only 29% of the patients were subsequently transfused. From the 384 units of blood ordered at admission 230 were returned unused. Inter-trochanteric fractures had a mean blood loss of 3.1g/dl (range 1.5–7.2g/dl) following surgery in comparison to a mean loss of 1.7g/dl (0.9–3.4g/dl) for patients with displaced subcapital fractures

Study 2

Orthopaedic trainees at all levels of training requested more blood then their anaesthetic counterparts for patients with femoral neck fractures. There was misconceptions regarding blood loss following surgery amongst all trainees and only 14.3% trainees used existing literature to guide their cross-match practice where as 53.4% devised protocols based on their own or colleagues’ experience.

Study 3

Cross-match protocol was working effectively. Only 16.7% of the patients with femoral neck fractures were cross-matched on admission.

Conclusion

Cross-match recommendations fail to influence trainees. In order to address this we produced a protocol that does not rely on orthopaedic trainees. The haematology MLSO provides the appropriate amount of preoperative blood for the patient based on our finding of blood loss of different fracture patterns and the patients’ preoperative haemoglobin level. Our results show our protocol is still effective two years following its introduction despite numerous changes in trainees during this period.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared test.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients and the production of pre-operative literature.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared tests on SPSS.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients, production of preoperative literature and for improving the service we offer to our patients.