The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome.

We used our arthroplasty database, which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) was identified. A control group of patients ≥ 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups. 40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees. Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10-year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004).

We conclude that Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.

The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome.

We used our arthroplasty database which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) were identified. A control group of patients > 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups.

40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period. (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees.

Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10 year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004).

Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.

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.

Supracondylar fractures of the humerus have historically been treated as an emergency case and operated on at the earliest opportunity. We undertook a study to examine whether surgical timing affects the need for open reduction or peri-operative complications in the type III injuries.

Between August 1995 and August 2004, 534 patients presented and were referred to our unit with these fractures. Those with closed, type III injuries without vascular compromise were selected (171 patients). These were divided into 2 groups: those undergoing surgery less than 8 hours from presentation (126 patients) and those undergoing surgery more than 8 hours from presentation (45 patients).

The two major differences between the two groups were: the delayed group were more likely to undergo open reduction (33.3% v 11.2%, p<0.05) and the mean length of the surgical procedure was increased (105.1 minutes v 69.2 minutes, p<0.05). Delay in treatment of the type III supracondylar fractures is associated with an increased need for open reduction and a longer procedure. We would recommend treating these injuries at the earliest opportunity.

We report the general mortality rate after total knee replacement and identify independent predictors of survival. We studied 2428 patients: there were 1127 men (46%) and 1301 (54%) women with a mean age of 69.3 years (28 to 94). Patients were allocated a predicted life expectancy based on their age and gender.

There were 223 deaths during the study period. This represented an overall survivorship of 99% (95% confidence interval (CI) 98 to 99) at one year, 90% (95% CI 89 to 92) at five years, and 84% (95% CI 82 to 86) at ten years. There was no difference in survival by gender. A greater mortality rate was associated with increasing age (p < 0.001), American Society of Anesthesiologists (ASA) grade (p < 0.001), smoking (p < 0.001), body mass index (BMI) <  20 kg/m² (p < 0.001) and rheumatoid arthritis (p < 0.001). Multivariate modelling confirmed the independent effect of age, ASA grade, BMI, and rheumatoid disease on mortality. Based on the predicted average mortality, 114 patients were predicted to have died, whereas 217 actually died. This resulted in an overall excess standardised mortality ratio of 1.90. Patient mortality after TKR is predicted by their demographics: these could be used to assign an individual mortality risk after surgery.

The purpose of this prospective study was to determine the predictive factors and hence optimal management of closed uncomplicated proximal radial fractures. We examined all patients presenting to our unit over an 18-month period with isolated closed proximal radial fractures. 237 consecutive patients were included. Demographic data, physical examination, radiographs, treatment and complications were recorded. Patients were reviewed at 2, 6, 12, 26 and 52 weeks post injury. Outcome was determined via functional assessment and Mayo Elbow Score (MES). Data were analysed using SPSS.

There were 156 (66%) radial head fractures and 81 (34%) radial neck fractures. 225 (95%) patients were treated non-operatively in a collar and cuff for one week followed by physiotherapy. 12 (5%) patients required primary surgical intervention due to either a mechanical block to forearm rotation (n=4) or a significant degree of radiographic comminution and/or displacement (n=8). Of the 201 patients who attended follow-up, 183 (91%) patients achieved excellent or good functional results measured on the MES. 155 (78%) patients achieved this by six weeks, with an average flexion arc of 125 degrees. Of the 12 patients treated operatively, the average MES at six weeks was fair (60). Regression analysis showed that increasing age, the AO-OTA fracture classification (B2.3, C2.3), radiographic displacement and operative treatment were significant predictors of a fair or poor outcome at six weeks.

The majority of isolated proximal radial fractures can be treated non-operatively with early mobilization, achieving excellent or good results within 6 weeks. Age, fracture classification, radiographic displacement and treatment choice are important factors that determine speed of recovery.

Purpose: To determine the outcome following anterior tibial spine avulsion in skeletally mature patients.

Summary: The study group comprised 83 knees with anterior tibial spine avulsion. The mean age of patients at injury was 35. Twenty knees with displaced tibial spine fractures were treated with fixation of the tibial spine and 63 patients with undisplaced or minimally displaced fractures were treated non-operatively.

Twenty two percent of the non operatively managed knees developed symptomatic instability and 10% of knees treated with tibial spine fixation developed instability (p=0.22). Stiffness was more common in knees treated with tibial spine fixation than in knees managed nonoperatively (60% vs 19%, p < 0.0005). There was a tendency for increased stiffness in older patients treated with surgical fixation of the tibial spine.

Conclusion: Tibial spine fracture in skeletally mature patients is associated with significant risk of knee stiffness and instability.

There is little evidence describing the influence of body mass index on the outcome of Total Hip Replacement (THR). There are concerns that an increasing BMI may lead to increased blood loss, infection and venous thromboembolism. 800 consecutive patients undergoing primary cemented THR were followed for a minimum of 18 months. The Harris Hip Score (HHS) and SF-36 were recorded pre-operatively and at 6 and 18 months post-operatively. In addition other significant events were noted, namely death, dislocation, re-operation, superficial and deep infection and blood loss. Multiple regression analysis was performed to identify whether BMI was an independently significant predictor of the outcome of THR.

No relationship was seen between the BMI of an individual and the development of any of the complications noted. The HHS was seen to increase dramatically post-operatively in all patients. BMI did predict for a lower HHS at 6 and 18 months, and a lower physical functioning component of the SF-36 at 18 months. This effect was small when compared with the overall improvements in these scores.

Conclusion: THR provides good symptomatic relief irrespective of BMI. On the basis of this study we can find no justification for withholding THR solely on the grounds of BMI.

This prospective study aimed to establish if octogenarians undergoing primary hip arthroplasty experienced a similar clinical outcome and complication rate as younger patients.

A total of 585 patients were recruited over a 4-year period. Patients aged 70–79 years and 80–89 years (octogenarians) were placed into separate groups.

Harris hip and SF-36 scores were obtained before and at 6 and 18 months following surgery. Other measurements included: blood loss; blood transfusion rate; wound infection; thromboembolism; dislocation and 90-day mortality.

Statistical analysis included a two-sample t-test and chi-squared analysis with Yates correction to compare results in each group. Analysis of covariance was used to calculate confidence limits for the effect of age group on Harris hip and SF-36 scores at 6 and 18 months after adjusting for levels recorded prior to surgery. Multiple logistic regression analysis was performed to determine any predictive factors for a noted difference in blood transfusion rates between patient cohorts.

A significantly better (P=0.019) improvement in mean Harris Hip score (SD) was seen 18-months after surgery in the younger cohort (43.4 (13.8) compared to 39.8 (10.6)). Length of hospital stay was longer (P< 0.001) in the octogenarians (12.9 (SD 7.0) days versus 10.1 (SD 4.7)) with a higher blood transfusion rate of 40% compared to 28% (P = 0.009). Lower pre-operative haemoglobin levels strongly correlated with the need for blood transfusion. No significant differences in infection, dislocation, thromboembolism or 90-day mortality rates were found.

Conclusions: Octogenarians are more likely to require blood transfusion and a longer hospital stay, with less improvement in clinical outcome at 18 months after primary hip arthroplasty.

Introduction and Aims: Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that aspirin decreased the fatal pulmonary embolism rate in patients admitted with a fracture neck of femur. In addition, new products (synthetic factor X inhibitor-Fondaparinux, and a direct thrombin inhibiter-Desirudin) have been reported to be more effective than low molecular weight heparin in preventing asymptomatic deep vein thrombosis. We felt it was important to repeat a survey, done in 1997, on the use of thromboembolism prophylaxis among British Orthopaedic Surgeons.

Method: A single page questionnaire was sent out to all 1308 consultants – orthopaedic surgeons who were members of the British Orthopaedic Association. Those who did not respond were sent a reminder letter.

Results: We achieved a 72% response rate. All surgeons use some form of prophylaxis. Eighty-five percent of surgeons use pharmacological prophylaxis. Low molecular weight heparin is used by 55% of surgeons. Twenty percent of surgeons use aspirin as their only form of pharmacological prophylaxis. Less than 1% (five consultants) use early mobilisation alone and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only form of prophylaxis. Seventy-four percent of surgeons have a unit policy. Thirty percent have changed their regime in the last three years.

Conclusion: The majority of British orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin, from 5% to 30%. Aspirin is often combined with a mechanical prophylaxis. This has led to an increase in the use of intermittent calf compression (3% to 22%), and foot pumps (12% to 19%). Low molecular weight heparin use has fallen by 10%.

Introduction Following any intraarticular fracture, joint range of movement and muscle strength recovery are vital factors in patient’s return to activities. Quadriceps weakness is a known complication of any injury affecting the knee. The purpose of this study was to investigate the recovery of knee ROM and quadriceps and hamstrings muscle strength in the first year after tibial plateau fracture and to assess factors that affect the recovery.

Method 63 patients were recruited over a 5-year period. Data regarding the age and sex of the patient, the mechanism of injury, the grade of the fracture according to Shatzker’s classification and the treatment received were recorded. All patients underwent a standard rehabilitation regime. At 3, 6 and 12 months after injury the patients were seen by a research physiotherapist. The range of movement was recorded. Thigh muscle peak torque was measured using isokinetic dynanmometry. The uninjured limb was used as the control – the peak torque in the injured limb was expressed as a percentage of the value in the uninjured limb to give the percentage recovery in the injured limb.

Results There was an initial extension deficit of 7° at 3 months, which improved to 3° at 12 months. Quadriceps strength recovery lagged behind that in the hamstrings at all times and only achieved only 77% at 12 months, compared to 90% in the hamstrings (p< 0.001). Patients under 40 outperformed those over 40 at each time point. At 12 months under 40s had achieved 85% recovery in their quadriceps, while over 40s only reached 74% (p< 0.01). Patient sex, mechanism of injury and grade of fracture had no effect on the level of recovery in this study.

Conclusion Patients who sustain a tibial plateau fracture have a residual small extension deficit and objective quadriceps weakness at 1 year post injury. Patient age has a significant effect on the level of quadriceps recovery. This information is useful when counselling patients who sustain these injuries.

Aim: To assess the results of total knee arthroplasty in a cohort of patients aged 80–89 years and compare them to a similar group of patients aged 70–79

Introduction: With the average age of the population steadily rising, more patients are likely to present with arthritis over 80 years of age. The benefits of Total Knee Arthroplasty (TKA) in the treatment of osteoarthritis are widely known, but there are few studies which examine the results of TKA in octogenarians.

Methods: Data was collected prospectively from 1995–2002 on 115 patients undergoing TKA aged 80–89 years and compared to 411 patients who were aged 70–79 undergoing TKA during the same period. Patients undergoing unicompartmental, revision or bilateral TKA were excluded. Patients were seen pre-operatively and scores for SF-36, American Knee Society (AKS) score and haemoglobin were taken along with demographic data. The outcome measurements used were SF-36 score, AKS score, blood loss, length of stay, mortality and post-operative complications. These were collected during the first week post-surgery and at 6 and 18 months post-surgery.

Results: Both groups showed significant increases in AKS score at 6 months, (54.17 and 54.45, both p=0.0001). We continued to see improvement of the AKS score up to 18 months (mean 85.38 and 85.12, p= 0.55) with no significant difference between the two groups. Patients over 80 had lower pre-op Haemoglobin (Hb) (mean 13.56 and 12.23, p=0.0001) but experienced the same Hb drop post-procedure. There was no difference in postoperative complications, but the length of stay (8.3 days and 13.9 days, p=0.0001) and mortality rate (0.7% and 5%, p=0.0001) were higher.

Conclusions: Our early results show that TKA can be beneficial to patients over 80 years in terms of mobility and independence, but they have a longer in-patient hospital stay and attract a slightly higher mortality risk at 90 days.

Introduction: There is little published on the outcome of orthopaedic surgery performed by surgeons in training. The individual results of orthopaedic units and consultants are coming under increasing scrutiny. There may be concerns that trainee performed THR will negatively impact on these figures. This study compares the outcome of THR’s performed by consultants and supervised trainees.

Methods: Data was prospectively collected on 139 THR’s carried out by supervised specialist registrars (years 1 to 4) and 397 THR’s carried out by consultants. The Harris Hip Score (HHS) was used as the primary outcome measure and scores were taken at 7days pre-operatively, 6 and 18 months post-operatively. In addition data on co-morbidity, blood loss, transfusion requirements, re-operation, dislocation and death were recorded. Radiographs of 110 trainee and 110 consultant performed THR’s were compared at 6 months. Acetabular anteversion and abduction and femoral orientation were assessed on lateral and AP films. Cementation was judged using methods described by Hodgkinson and Barrack.

Results: Blood loss, transfusion requirement, dislocation, revision, deep infection and the HHS at 6 and 18 months showed no statistically significant difference between trainee and consultant (all p< 0.05). Component orientation and cementation quality again showed no significant difference (p< 0.05).

Discussion: This paper reveals no difference in the short term results of THR performed by consultants and supervised trainees. Our results show that quality can be maintained whilst training juniors to operate.

Background: Previous studies have reported mixed findings with regards to post operative complication rates and overall outcome in elderly patients undergoing total hip arthroplasty. The aim of this study was a prospective comparison of physical and functional outcome measurements following primary hip arthroplasty in patients aged 80–90 years to those aged 70–79.

Methods: Data was prospectively recorded from 1998–2002. 144 patients aged 80–90 years underwent primary hip arthroplasty compared to 441 aged 70–79. A pre-operative Harris Hip Score was obtained on all patients and a standardized follow up regimen was used for assessment at 6, 18 and 36 months post surgery. Data collection included: intraoperative blood loss; post operative transfusion rate; incidence of wound infection, DVT and pulmonary embolus; dislocation and mortality rates. Statistical analysis involved two-sample t-test and chi-squared with Yates correction.

Results: Pre-operative Harris Hip Scores were 41.6 (SD 11.2) in the younger cohort and 39.3 (SD 12.4) in the octogenarian (P = 0.04). This score had improved by 39.3 and 38.1 points respectively (P = 0.5) at 6 months; 42.3 and 37.7 at 18 months (P = 0.02); 43.4 and 39.8 at 36 months (P = 0.24).

The mortality rate at 3 months following surgery was 4% in our octogenarian group compared to 1% (P=0.02). Mean length of hospital stay was significantly (P< 0.001) longer at 12.9 (SD 7.0) days compared to 10.1 (SD 4.7). The transfusion rate in our octogenarian group was 40% compared to 28% (P = 0.009). The incidence of deep infection was 1.4% in the older group compared to 0.5% (NS). Each group had a dislocation rate of 1%. and an incidence of DVT and pulmonary embolus that was comparable.

Discussion: Total hip arthroplasty can be performed safely in octogenarians with excellent relief of pain and improved function.

Introduction: There is little evidence describing the influence of Body Mass Index (BMI) on the outcome of Total Hip Replacement (THR). There are concerns that an increasing BMI may increase complication rates such as superficial and deep infection, blood loss, operation time and aseptic loosening. There is evidence that obese patients receive good symptomatic relief from THR and so it is important that the advisability of surgery is made on good evidence.

Methods: 800 patients undergoing primary Charnley total hip replacement were followed prospectively for a minimum of 18 months. The Harris Hip Score (HHS) and SF-36 were recorded pre-operatively and at 6 and 18 months post-operatively. Other significant events were noted, namely death, dislocation, re-operation, superficial and deep infection and blood loss. Stepwise multiple regression analysis was performed to identify whether BMI was an independently significant predictor of the outcome of THR.

Results: The mean age of patients was 68 years, with 61% females. At 18 months 31 patients (39 hips) had died. There were 15 re-operations, 13 dislocations and 7 deep infections.

No relationship was seen between the BMI of an individual and the development of post-operative complications. The HHS was seen to increase dramatically postoperatively in all patients (mean 43 points at 18 months). BMI did predict for a lower HHS at 6 and 18 months and a lower physical functioning score on the SF-36.

Discussion: THR produces a significant improvement in symptoms in patients, irrespective of BMI. An increasing BMI does not result in an increase in the early complication rate following THR. There is a reduction in the HHS and physical function component of SF-36 with increasing BMI, although this effect is small. On the basis of this study we do not think that THR should be withheld solely on the grounds of BMI.