The risk of venous thrombo-embolism (VTE) is high in orthopaedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post-operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out a questionnaire to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then once a day for 14 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was confirmed by Doppler or CTPA as Deep Vein Thrombus or Pulmonary Embolism. Minor bleed was categorised as dressing soakage or reported wound leakage, major bleed as haematoma requiring revision within 30 days.

509 patients underwent TKR: 200(39%) only received Rivaroxaban (Group 1), 296(58%) also received tranexamic acid (Group 2). 13(3%) of patients had no data available. 5 patients had a VTE: 4 (2%) Group 1, 1 (0.3%) Group 2 (P<0.05). 39 patients had a minor bleed: 17 (8.5%) Group 1, 22 (7.4%) Group 2 (P=0.5). 2 patients had major bleeds: 1 (0.5%) Group 1, 1 (0.33%) Group 2 (P=0.69). Blood transfusions 21: (10.5%)Group 1, 9 (3%) Group 2 (P<0.0001).

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results whilst they show a trend towards decrease bleeding rates in both the minor and major bleeds are not significant, requiring larger studies looking at wound bleeding and leakage.

Rivaroxiban is a factor Xa inhibitor and is a newer oral alternative for thromboprophylaxis after joint replacements. Its major advantage is its oral administration and hence better patient compliance. However there are some doubts about its efficacy compared to dalteparin/heparin. We have recently changed over from using dalteparin injections to rivaroxiban tablets for thromboprophylaxis after hip replacements. We assessed our results to find efficacy and specificity of its action in patients undergoing THR.

504 patients underwent hip replacement in last 2 years. 316 were treated with dalteparin injections (fragmin) for thromboprophylaxis while 189 patients were treated with oral rivaroxiban for 35 days after their hip replacement.

Average haemoglobin drop at 24 hours postop was 2.79 in Rivaroxiban group compared to 3. 10 in dalteparin group. 19 patients (of 189 i.e. 10.05%) required postop blood transfusion in rivaroxiban group as against 60 (of 315 i.e. 19.04%) in Dalteparin group. This difference was statistically significant. Incidence of DVT was no different in either groups, but the number of patients was too small to compare this.

Rivaroxiban appears to be more specific in its action and our results suggest a significant reduction in postop blood transfusion following hip replacements without any increase in rate of Deep Vein Thrombosis. We would like to present our findings and discuss role of oral thromboprophylaxis after joint replacements.

Aim

To compare the results of total knee replacement in a consecutive series of morbidly obese patients (body mass index (BMI) > 40 kg/m²) with a matched group of non-obese (BMI< 30 kg/m²) patients.

Pre-operative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA).

We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on pre-operative age, sex and body mass index (BMI).

There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P<0.001).

Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P<0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 - 21.7 with a cardiac history compared to 4.8 - 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, nor did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA.

The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history.

This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors.

Introduction

We report the results of a prospective study of 1349 patients undergoing 1509 total knee replacements, identifying factors increasing the risk of infection.

The Depuy Sigma Total Knee Arthroplasty (TKA) was introduced in 1997 as a modification of the Pressed Fit Condylar (PFC) TKA. It is the most commonly used TKA in England and Wales, accounting for 34.9% of all primary TKAs performed in 2006. The PFC has reported 10-year survival rates of 90–95%. This study reports the first clinical and radiological outcomes at 7–9 years following TKA using the PFC Sigma prosthesis.

Three hundred and eighteen consecutive Sigma TKAs were performed in 275 patients between October 1998 and March 2000. Patients were prospectively followed up in a specialist nurse-led clinic. Final review was performed in December 2007 or January 2008, i.e. 7–9 years post surgery. Outcome measures included American Knee Society Scores, Radiographic Scores and Oxford Knee Scores. Survival analysis was performed using the life table method.

Of 318 Sigma knees, 225 (193 patients) were alive at 7–9 years. 6 knees in 5 patients were lost to follow up. 7 knees (2.2%) were revised: 6 for infection within the first two years and 1 at 59 months who underwent isolated change of polyethylene insert. The 9-year survival was 97.7% with revision for any reason as endpoint and 99.6% with revision for aseptic failure as endpoint. The mean American Knee Society Knee score was 84/100 at 7–9 years compared with 33/100 pre-operatively. 0f 140 radiographs, 48 knees had radiolucent lines but no knee showed radiological evidence of loosening.

These results suggest that the Sigma TKA gives excellent clinical results up to 9-years.

Hip and knee arthroplasty account for over 95 000 hospital days annually in Scotland. The gross cost of over £81 million can be reduced by £10 million by decreasing length of stay by just one day per patient.

We performed a retrospective analysis of the data from the Scottish Arthroplasty Project (SAP). We specifically looked at length of stay in patients undergoing total hip and knee replacements between 1996 and 2007. We analysed the data on over

91000 total hip and knee replacements. In addition we looked at the influence of age, volume and day of admission on the 2007 data

Over the 11 year period there were significant variations in improved length of stay across the health boards. For the 2007 data, we found that patients treated in boards with high patient volume had shorter hospital stays. Admission policy and age of the patients affected the length of stay it did not account for the large differences between health boards.

The data from the Scottish Arthroplasty Project shows that higher surgical volume correlates with reduced length of stay in arthroplasty patients. The reasons for this are likely to be multifactorial but generalisable and need to be examined more closely with another study.

Whilst clinical pathways have reduced the length of inpatient stay (LOS) and costs associated with total hip replacement (THR), it would be useful to be able to predict which factors affect the LOS following THR. In this way units could improve patient flow, and thus increase efficiency, by optimising case loads and staffing levels in all related departments. We hypothesised that there were pre-operative factors that will predict the length of inpatient stay following a unilateral primary THR.

Prospective data from 2302 patients who underwent primary unilateral THR for osteoarthritis during a nine-year period from January 01 1998 were included. The relationship between each prospectively recorded factor and LOS was analyzed separately using t-tests or Pearson correlation. Multiple linear regression was used to analyze the effect of each significant factor adjusted for others.

Length of stay varied from 3 to 58 days, with a mean of 8.1 and a median of 7.0. The pre-operative factors that were not significantly associated with the LOS were BMI, Scottish Index of Multiple Deprivation, disabling knee, back or contra-lateral hip pain. A number of pre-operative factors were found to be highly significant predictors of LOS when subjected to univariate analysis, but not significant after multivariate analysis. These were smoking, heart disease, diabetes, pre-operative aspirin, pre-operative haemoglobin and overall Short Form (SF-36) score. Pre-operative factors that were significantly associated with LOS after adjusting for the effect of others were age, sex, pre-operative NSAIDs, consultant surgeon, combined function/activity dimension to Harris hip score, general health perception (GHP) dimension of SF-36, the day of the week and the year of surgery.

Younger age, male sex, higher combined Harris hip function and activity score, higher GHP dimension of SF-36 score and NSAID use are all significantly associated with reduced length of inpatient stay following primary THR for osteoarthritis.

Despite increasing scientific investigation, the best method for preventing post-operative deep vein thrombosis remains unclear in patients undergoing a total hip replacement. In the wake of the recent controversial National Institute for Health and Clinical Excellence Clinical Guidelines on the prevention of thrombo-embolism, we felt it was timely to survey current Scottish Surgeons thrombo-prophylactic practice when performing total hip replacements.

E-mail questionnaires were sent to all Scottish Orthopaedic consultants. They were asked about routine pharmacological and mechanical prophylaxis in patients undergoing total hip replacement. Comparison was made with a previous survey done in 2003.

The response rate was 75%. The survey showed an increased use of pharmacological prophylaxis from 93% to 100%. This was due to the increased use of aspirin, from 51% to 64%. The use of Low molecular weight heparin had remained the same at 51%. No surgeons routinely use Warfarin, low dose heparin or Fondaparinux. Use of graded compression stockings has increased from 59% to 70%.

There is increasing evidence that patients undergoing total hip replacement should receive extended prophylaxis for up to 35 days. This could explain why aspirin is commonly used. Most guidelines, however, do not recommend this drug. With the recent launch of two new oral agents we may see a huge change in prophylaxis in Scotland, as 94% of surgeons said they would use extended prophylaxis if a safe oral agent was found.

Our aim was to identify intra-operative and post-operative factors that predict those patients most at risk of dislocation.

Data was prospectively collected on a consecutive series of 2899 total hip replacements undertaken between July 1997 and December 2007. All operations were undertaken in one institution by fourteen orthopaedic consultants. In order to ensure accuracy, our regional database was cross-referenced with the Scottish Arthroplasty Project. Age; sex; BMI; surgeon; surgical approach; monthly caseload per surgeon; and the head size of the implanted prosthesis were analyzed using chi-squared tests for categorised factors and t-tests for quantitative factors.

Of the 2899 patients, 78 (2.7%) were found to have had one or more dislocation. BMI > 35kg/m2 was a significant pre-operative predictor of dislocation (P< 0.001). BMI < 35kg/m2 had a dislocation rate of 2.3% compared with a rate of 6.7% in those > 35kg/m2. Operating surgeon was the only intra-operative factor predictive of dislocation (P< 0.001). Head size was found to be insignificant.

Three surgeons with an overall dislocation rate of < 1% had a dislocation rate of 0.8% for patients with a BMI < 35kg/m2 and 2.0% for BMI > 35kg/m2. In comparison, the remainder of the surgeons had rates of 3.3% for BMI < 35kg/m2 and 9.6% for BMI > 35kg/m2.

Analysis of this consecutive series has shown that a BMI > 35kg/m2 is associated with a significant increase in rates of dislocation. The operating surgeon is also a significant factor and the highest risk is seen in surgeons with a > 1% overall dislocation rate operating on obese patients.

In Scotland, the number of primary total knee replacements (TKRs) performed annually has been steadily increasing. Data from the Scottish Arthroplasty Project has recently demonstrated that the number of knee replacements performed annually has now outstripped the number of hip replacements. The price of the implant is fixed but the length of hospital stay (LOHS) is variable. An understanding of what currently influences LOHS may therefore be of paramount importance in order that we can influence some of these parameters, with resulting benefit to our patients as well as contributing significantly and favourably towards the health economics of this procedure. This study investigates the influence of intra- and post-operative variables on LOHS.

All patients who underwent primary unilateral TKR in the region of Fife, Scotland, United Kingdom, during the period December 1994 to February 2007 were prospectively investigated. The following intra and postoperative details were recorded: length of operation, need for urinary catheterisation, patella resurfacing, lateral release, blood transfusion, the presence of superficial or deep infection, day 1 post-operative haemoglobin and haemoglobin drop (haemoglobin drop between admission haemoglobin and day 1 post-operative haemoglobin). The data was analysed using univariate and multiple linear regression statistical analysis.

Data on LOHS was available from a total of 2105 primary unilateral TKRs. The median LOHS was 8.0 days. The highly significant intra and post-operative factors associated with an increased LOHS were lateral release, post-operative haemoglobin, blood transfusion, urinary catheterisation, deep and superficial infection. An awareness and understanding of these factors may enable us to influence them favourably with resulting reduction in the LOHS and, therefore, the associated costs.

Introduction: Total Hip Replacement (THR) is an effective procedure that improves Quality of Life (QoL) in patients with hip arthritis. Co-existing back pain is common in these patients. We assessed the impact of back pain on the medium term outcomes of patients undergoing unilateral THR using a disease specific measure, Harris Hip Score (HHS) and a general health questionnaire, Short Form-36 Health Evaluation (SF-36). The SF-36 generates scores on 8 dimensions of QoL; physical functioning (PF), role limitation due to physical problems (RP), role limitation due to emotional problems (RE), social functioning (SF), mental health (MH), energy/vitality (EV), bodily pain (Pain) and general health perception (GHP). It also contains an item requesting information on perceived health change over the past year (CH).

Methods: Between 4th January 1998 and 22nd July 2001, 909 consecutive patients undergoing unilateral THR were entered into a regional arthroplasty database. An audit nurse collected data prospectively. Patients were assessed pre-operatively and demographic details recorded. Patients were asked specifically about the presence or not of back pain. Post-operative follow up was at 6 mnths, 18 mnths, 3 yrs and 5 yrs. At each point the HHS and SF-36 were measured.

There were more females in our study population (61.2% v 38.8%). Statistical analysis was performed for males and females after adjusting for age, body mass index and pre -op scores.

Results: Pre-op, mean HHS and SF-36 score were lower for patients with back pain. Post-THR, patients had overall better outcome scores. Male patients with back pain had significantly lower (P< 0.01) post-THR outcome scores at all time points for HHS, PF, SF and Pain compared to their male peers without back pain. These changes persisted to 5 yrs. This effect was not demonstrated in female patients. The only exception was in the Pain domain of SF-36 where female patients with back pain had lower scores (P< 0.01) than those without back pain.

Conclusion: Patients with back pain obtain significant benefit from unilateral THR in the medium term and this is maintained at 5 yrs. Despite the clinical benefit to the group as a whole, the absolute scores for males with pre-op back pain remain significantly lower than their peers without back pain. Pre-op back pain did not significantly affect outcome in females.

Introduction: Increasingly, clinical pathways and fast-track protocols are reducing hospital in-patient stay following elective joint replacement surgery. In order to improve efficiency in our unit, we undertook a prospective observational study to identify pre–and peri-operative factors associated with increased length of stay.

Methods: From our prospective primary hip arthroplasty database we analysed data from 2678 consecutive patients over a 9-year period from 1998–2007. Patients were excluded who had bilateral hip replacement, died within 30 post-operative days, or had surgery for a diagnosis other than primary osteoarthritis. This left 2302 patients who were analysed using multiple logistic regression analysis

Results: Length of stay varied from 3 to 58 days, with a mean of 8.1 days, and median 7 days. After multivariate analysis, factors that were found to be significantly associated with shorter length of stay were younger age (p< 0.001), male sex (p< 0.001), more recent year of admission (p=0.008), regular non-steroidal anti-inflammatory medication (p< 0.001), lower Harris Hip Score (p< 0.001), and higher General Health Perception dimension score on SF-36 questionnaire (p< 0.001). In addition, the absence of blood transfusion during admission (p< 0.001) and absence of post-operative urinary catheter (p< 0.001) were also associated with shorter length of stay. The following factors, in particular, were not found to be significantly associated with increased length of stay: obesity, diabetes, smoking, medical comorbidity, other disabling joint condition, use of wound drain post-operatively.

Conclusions: We have identified a number of pre-operative factors that predict likely length of stay in a large cohort of patients undergoing primary hip replacement. This data could be used in the future for resource allocation and to improve efficiency in this significant area of healthcare.

Introduction: In Scotland, the number of primary total knee replacements has been steadily increasing since 1992. It has been predicted that the number of total knee replacements performed annually will soon outstrip the number of hip replacements. The price of the implant is fixed but the length of hospital stay, and associated cost, is variable. An understanding of what currently influences length of hospital stay may be of paramount importance in order that we can influence some of these parameters, with resulting benefit to our patients as well as contributing significantly and favourably towards the health economics of this procedure.

Materials and Methods: All patients who underwent primary unilateral total knee replacement in the region of Fife, Scotland, UK, during the period December 1994 to February 2007 were prospectively investigated. The following information was gathered: age, sex, body mass index (BMI), year of operation, day of operation, diagnosis, surgeon grade, consultant performing the operation, walking score, walking aids score, stair score, American Knee Society score (pain, stability and range of motion), length of operation, need for lateral release, patella replacement, urinary catheterisation, blood transfusion, presence of deep or superficial infection, pre and post-operative haemoglobin values, haemoglobin drop, and length of hospital stay. All the data was analysed using univariate and multiple linear regression statistical analysis.

Results: Data on length of hospital stay was available from a total of 2105 unilateral total knee replacements. Length of stay varied from 4 to 70 days, with a mean of 9.4 and a median of 8.0. There were numerous highly significant predictors of increased length of hospital stay, when considered separately. Many of these independently significant factors remained significant when adjusted for the effects of the others. These included age of the patient, year of admission, consultant performing the operation, use of a walking aid, lateral release, deep and superficial infection, pre and post-operative haemoglobin values, urinary catheterisation and blood transfusion. Of note, the day of operation and high BMI did not influence the length of stay.

Conclusion: Prolonged hospital stay following total knee replacement is associated with demographic, preoperative, intra-operative and post-operative factors. An awareness of these factors gives us the opportunity to make attempts to influence them favourably with resulting reduction in length of hospital stay and, therefore, the associated costs.

Chondrocytes are responsible for the mechanical resilience of cartilage by controlling the synthesis/degradation of the extracellular matrix. In osteoarthritis (OA), increased activity of cytokines/degradative enzymes (e.g. IL-1beta, MMP-13) play a key role leading to matrix breakdown/cartilage loss. Studying early events in OA might identify targets for limiting the deleterious changes to cartilage stability. Human chondrocyte shape in situ is normally elipsoidal/spheroidal however abnormal forms within otherwise macroscopically normal cartilage are present. Changes to cell shape can alter ECM metabolism and thus these abnormal forms might be an early event in OA. We have investigated whether levels of IL-1beta and MMP-13 are altered in human chondrocytes of abnormal morphology.

Tibial plateau cartilage was obtained from patients undergoing knee arthroplasty and only areas graded 0 or 0–1 studied. The shape of fluorescently-labelled in situ chondrocytes was classified by confocal scanning laser microscopy with cartilage depth, and cells characterised as normal (no cytoplasmic processes) or abnormal (one/more cytoplasmic process). Within grade 0 cartilage about 40% of the cells demonstrated abnormal morphology with a reduced proportion in deep zones. Fluorescence immunohistochemistry of antibodies for IL-1beta or MMP-13 was studied in the same cells and quantified. There was an increase in IL-1beta fluorescence with abnormal chondrocytes within the superficial (p=0.033; 21 joints > 190 cells) and deep zones (p=0.001; 8 joints > 100 cells). There were no differences between MMP-13 labelling of normal compared to abnormal chondrocytes within either the superficial or deep zones.

Our results suggest that in relatively non-degenerate cartilage, a proportion of the chondrocyte population demonstrated abnormal morphology and that these cells have elevated levels of IL-1beta but not MMP-13. However, we do not know if chondrocyte shape alters cytokine levels, or vice versa. Additionally, the role of cartilage age is unclear, as although the cartilage samples were relatively normal they were obtained from aged individuals. Nevertheless these results show changes to chondrocyte morphology and increased levels of IL-1beta, and thus presumably matrix catabolism - in relatively normal human articular cartilage, raising the possibility that this is an early event in cartilage degeneration.

Supported by the Wellcome Trust (075753).

Loss of blood is inevitable during knee replacement surgery, sometimes requiring transfusion. Allogenic blood leads to a risk of disease transmission and immunological reaction. There are various practices used. There is still a risk of bacterial transmission with stored blood and haemolytic transfusion reactions can still occur. Data was collected between 1998 and 2006. There was data on transfusion in 1532 patients undergoing primary knee replacements. There were 1375 unilateral TKRs and 157 bilateral TKRs. After reducing the bilateral cases to one record per patient, it was agreed to restrict the main analysis to 1532 patients. Data was collected prospectively at a pre-admission clinic 3 weeks prior to surgery. Haemoglobin was checked and body demographics including BMI were obtained. Each patient also had a knee score assessed. All patients received a LMWH pre-op until discharge. A tourniquet was used in each case and all patients had a medial para-patellar approach. No drains were used and operation details such as a lateral release were recorded. As per unit protocol, patients with a post-op haemoglobin less than 8.5g/dl were transfused as were symptomatic patients with haemoglobin between 8.5g/dl and 10g/dl. Each of the possible predictive factors was tested for significant association with transfusion using chi-squared or t-tests as appropriate. Multiple logistic regression was used to test for the independent predictive of factors after adjusting for one another. Results show that transfusion was more likely if the patient was older, female, short, light or thin. Among peri-operative factors, the chance of a transfusion was increased for bilateral patients, those with low knee scores and those with high ASA scores. Also patients undergoing a lateral release, those with low pre-op haemoglobin and those with a large post-op drop were more likely to be transfused. All the significant variables were entered into a forward stepwise multiple logistic regression. Transfusion was significantly more likely in those undergoing a bilateral procedure, with a low BMI, low pre-op haemoglobin and those with a large post-op drop (> 3g/dl). Allogenic transfusion is associated with immune-related reactions, from pyrexia to urticaria to haemolytic transfusion reactions, which can be life threatening. There is also the risk of viral pathogen transmission. Women were shown to be almost twice as likely to need transfusion. This has been shown in previous studies and is thought to be due to women having a lower weight and pre-op haemoglobin, both of which were shown to be significant independent factors in increasing the risk of transfusion. A pre-operative haemoglobin of less than 13g/dl, a BMI less than 25, and undergoing a bilateral procedure were shown to have an increased risk of transfusion. For patients falling into these categories, measures can be planned to try and reduce this risk.

Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives.

We also had data on preoperative age, sex and body mass index (BMI).

There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P< 0.001).

Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P< 0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 – 21.7 with a cardiac history compared to 4.8 – 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA.

The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history.

This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors.

Aim: To study the effect of smoking on the rate of complications and functional outcome after Total Hip Replacement (THR).

Methods: Data was prospectively collected for all patients undergoing a unilateral, primary THR in one hospital during the period 1998 to 2006 Data was collected at pre-operative assessment, in the peri-operative period and at 6 months, 18 months, 3 years and 5 years. Patients were placed in one of three groups; smokers, ex-smokers and those who had never smoked.

Outcome measures included rate of complications: infection, DVT, PE, length of hospital stay and Harris Hip Score (HHS).

Statistical analysis was undertaken to determine any correlation between smoking and these outcome measures using chi-squared tests, t-tests and multiple regression adjusting for confounding factors.

Results: 1765 patients underwent THR during the study period, of whom 635 were males and 1130 females, with a mean age at operation of 69.

268 patients (15%) were smokers, 582 patients (33%) were ex-smokers and 917 patients (52%) had never smoked. As there was little data available on when the ex-smokers had stopped smoking we studied current smokers compared to patients that had never smoked

There were no significant differences in complications such as DVT, PE, Deep infection and Superficial infection, these were all rare events. Neither was there any significant difference in hospital stay times. After adjusting for pre-operative HHS, age, sex and ASA status current smokers had significantly lower HHS at 6 months (p< 0.001, 95% confidence interval for effect size 1.6 to 5.3), and also showed a lower HHS at 18 months, 3 years and 5 years although not significantly so.

Conclusion: Current smokers have a significantly lower HHS post-operatively in comparison to non-smokers. In a health system where more and more patients wish to know the risk associated with potential operative interventions, we can now say that patients who smoke will have a poorer outcome post Total Hip Replacement. This may also allow us to discourage some patients wishing to have THR whom are poor operative candidates.

We plan to further analysis the data to try and ascertain why this is the case.

Introduction: Pharmacological and mechanical methods are recommended to prevent venous thromboembolism (VTE) following hip replacement (THR). However, data on mechanical methods such as graduated compressive stockings (GCS) are limited. This study examined the efficacy and safety of GCS when added to fondaparinux.

Methods: The randomised treatments were 2.5 mg fondaparinux for 5–9 days starting postoperatively alone or with GCS for 42±7 days. The primary efficacy outcome was VTE or sudden death prior to Day 42±7. All patients were to have duplex USS at day 42 + 7. VTE was defined by verified symptomatic VTE or asymptomatic proximal DVT. The main safety outcomes were major and minor bleeding and VTE death.

Results: 856 patients were randomised, of which 799 were THR patients. Of these 756 (95%) were evaluable, 377 in the fondaparinux and 379 in the fondaparinux plus GCS groups. Risk factors for thrombosis were recorded (age > 75 in 20%, history of obesity in 21%, cancer in 6% and VTE in 3%). Compliance with GCS was high, with 85% wearing them continuously. The primary efficacy outcome of VTE or sudden death in THR patients was similar in each treatment group, the results were 5.5% in the fondaparinux only group and 5.3% in the fondaparinux with GCS group; odds ratio was 0.96, 95% confidence interval 0.50–1.83, p=0.91. Outcomes were not different for long-length and short-length stockings. Major bleeding occurred in one patient (< 1%), minor bleeding in 6.7%. No VTE deaths were reported.

Discussion: The addition of GCS to fondaparinux showed no benefit in thromboprophylaxis over fondaparinux alone in this large study of THR patients. Therefore GCS may not be indicated in patients receiving fondaparinux. Graduated compression stockings are time consuming to measure and fit, inconvenient and expensive; therefore we recommend a reconsideration of this current and commonly used practice in THR.

Background: Intracapsular neck of femur fracture (# ICNOF) is one of the most common fractures in the elderly. In octa and nonagenarians, with age associated and other co morbidities, achieving a pre injury status of mobility is the deemed result. The physiological age, rather than the chronological one is an important factor determining the type of joint used and results in these patients.

Aim: We present here, a study of 349 patients in the age group of 80 to 100, who underwent hemiarthroplasty as primary treatment for # ICNOF.

Patients and Methods: We studied the data from a prospective hip database of patients undergoing hemiarthroplasty for # ICNOF between Jan 2000 and Jan 2005. All patients admitted with # ICNOF in our centre are assessed by a Hip audit nurse. Pre and post operative data is collected in a specific format. Patients undergo hemi-arthroplasty usually within 24 hours of admission. The type of joint used in decided by the operating surgeon. Patients were reviewed at the 4 month mark after the surgery. They were assessed for pain, mobility and complications. Seven outcomes and eight possible confounding factors were considered and statistical comparison was done to find specific correlation between these factors.

Results: 613 patients underwent hemiarthroplasty during the said period. 349 of these were more than 80 years of age. The mortality and mobility in this group was studied and various factors determining the outcome were assessed and statistical correlation tested. The mortality was expectedly higher in elderly population. Post operative mobility was mainly related to the preoperative functional status. In addition, age, other co-morbidities, ASA grade and joint type also had bearing on the Results:

Discussion: We are a busy District General Hospital in Scotland and hemiarthroplasty for # ICNOF is one of the routinely performed surgeries with more than 100 patients undergoing this procedure in a year. We have a dedicated Hip audit nurse who is responsible for maintaining a database for all these patients.

With increasing age of the population, # ICNOF in over 80s has evolved into a commonly encountered problem. Early mobilisation and aiming for pre injury functional status is an achievable goal in most. ‘The better they walked before, the better they will walk after’ is the golden rule to predict outcome. We use uncemented Austin Moore prosthesis for all patients but prefer to use a bipolar uncemented HAP coated prosthesis (JRI Furlong prosthesis) for patients who are relatively active and independent, regardless their age. The early results in this second group of patients are predictably better, but it will require further detailed study to determine whether these hold true in long term as well.