Background: Back pain is a common presenting feature in patients with hip arthritis. Hip replacement surgery is performed primarily to relieve hip pain but is known to improve global function. The aim of this study was to quantify the effects of total hip arthroplasty on back pain.

Patients and Methods: A prospective study was conducted from 2001 to 2005 at the Victoria Hospital, Kirkcaldy, Fife. A novel body diagram was devised to collect and quantify back pain. Patients were asked to localize their pain on this diagram prior to their surgery and six months later. The patients were also asked to record their level of satisfaction on a visual analogue scale (VAS) and to complete validated functional and psychological assessments (SF-36; Harris Hip Score).

Results: Preoperative and postoperative data were complete for 872 patients. Preoperatively, 234 (27%) patients complained of pain in the lumbar region. A low score in the baseline SF-36 correlated with low back pain. At six-month post total hip arthroplasty, the low back pain had resolved in 50% (n=116) of these patients, and resolution of this pain correlated with improved post-operative SF-36 score. The mean postoperative satisfaction score was 8.8 out of a maximum 10 (VAS). Satisfaction correlated with reduced back pain.

Conclusion: We describe a novel method of pain assessment in total hip arthroplasty. These data from a large prospective cohort indicate that many patients may expect an improvement in their back pain following hip replacement. This data will be useful in the preoperative counselling of patients considering arthroplasty.

Introduction: We report the results of activity and functional outcome of matched pair analysis comparing hip resurfacing with total hip replacement with a minimum follow up of 22 months

Materials and Methods: 14 matched pairs were selected in terms of age (within 4 years), sex and diagnosis, of which 10 pairs were females and 4 pairs were males The mean age was 49.7(19 – 63). The Birmingham hip resurfacing was used in all patients in the resurfacing group and the Furlong HAC stem in all cases in the THR group with the CSF cup in most cases. The mean follow up in BHR group was 5.2 years (1.7 – 9.2) and 2.4 years (1.8 – 3.6) in THR group. Functional outcome was measured using Harris Hip score, WOMAC, SF 36 and the UCLA and Tegner activity scores

Results: The mean Harris Hip score, SF 36, WOMAC, UCLA and Tegner activity scores in the BHR group were 86.8, 77.3,49.7, 6.1 and 3.6 respectively. In the Furlong group the Harris Hip score, SF36, WOMAC, UCLA and Tegner activity scores were 82.9, 79.0,29.5, 5.6 and 3.2 respectively. There was no statistical difference in the mean scores between the two groups.

With regard to functional activity, 21% of patients in both the groups scored 8 or more on the UCLA activity scale. 21% of patients in the BHR and 14% in the Furlong group scored 3 or more on the Tegner activity scale

Conclusion: In our study, hip resurfacing was not associated with a significant increase in activity level or functional outcome compared with total hip replacement.

Background: Long bone fractures and intramedullary stabilisation can result in the extravasation of fat and marrow emboli into the venous circulation. The effects of these emboli can become systemic causing neurological features.

Aim: To establish the cerebral microembolic load following femoral and tibial diaphyseal fractures treated by intramedullary fixation and to specify any neurological impairment with the application of a series of cognitive tests and a serum marker of neuronal injury.

Methods: 20 femoral and tibial fractures treated with intramedullary fixation had intra-operative transcranial doppler ultrasound monitoring of the middle cerebral artery with emboli detection software set to established guidelines. Cognitive testing (day 3), following surgery with an I.Q. assessment (PFSIQ) allowing comparison with age specific normative data. This included: verbal fluency and speed (COWAT – Control Oral Word Association Test); working memory with assessment of immediate and delayed recall; mini-mental state examination; executive function, attention and mental processing speeds (Colour Trails 1& 2). Beta S-100 levels measured pre-operatively, 0, 24 and 48 hours following surgery as a marker of neuronal injury.

Statistical Analysis: One sample Wilcoxon signed rank test to compare median of the cognitive scores with age matched normative data. Multiple regression analysis used to correlate embolic load with cognitive function.

Results: Mean age (SD) for the group is 32 (5.8). Mean PFSIQ of 52.8%, SD 21.4 [median 59.5, IQ range 28.3, 71.3]. No significant difference detected in cognitive testing compared with normative data. Cerebral microemboli detected in 17 of 20 patients with a count median (range) of 6 (0, 29). The mean pre-operative beta S-100 level was 0.36 micro g/l (normal range 0–0.15). This increased to a peak mean of 0.88 micro g/l immediately following surgery with a poor correlation to cerebral embolic load.

Discussion: Detailed clinical testing indicates no significant deterioration in cognitive function following intramedullary stabilisation of these fractures. A variable cerebral micro-embolic load was seen but with no detectable clinical effect. No direct correlation was found between the elevated levels of Beta S-100 seen following surgery and cerebral embolic load. This appears to correlate with previous concerns in the literature regarding the specificity and sensitivity of this established marker of neuronal injury.

Introduction Damage Control orthopaedic techniques have been proposed in the seriously injured with primary external fixation of long bone fractures, reducing the ‘second hit’ of surgery. We have developed a large animal (ovine) model for the study of major trauma.

Aim To clarify the sequence of pulmonary and systemic physiological responses over a 24-hour period following injury, comparing the effects of primary external femoral fixation to intramedullary stabilisation to better quantify the ‘second hit’ of these surgical techniques.

Methods Under terminal anaesthesia bilateral femoral diaphyseal fractures were produced using a mechanical pneumatic actuator (ram). Hypovolaemic shock was maintained for 4 hours before fluid resuscitation and surgical stabilisation.

24 sheep were randomised into 4 groups and monitored for 24 hours following injury:

Group 1 – Control Group (effects of general anaesthesia only)

Group 2 – Control Group for Trauma (injury but no long bone stabilisation)

Group 3 – Damage control group (Injury and external fixation)

Group 4 – Early total care (Injury and reamed intra-medullary stabilisation)

Outcome measures: Embolic load (Mayo score) using transoesophageal echocardiography; serum markers of coagulation (prothrombin time, activated partial thromboplastin time and fibrinogen levels) and inflammation (interleukin 6). Bronchoalveolar lavage to assess total cell count and cell differential to quantify the proportion of neutrophils present.

Results A sustained embolic shower was detected with each femoral fracture (mean Mayo score of 5 and 5.5 respectively). Intramedullary reaming and nailing produced further embolic events with a mean score of 2.5 and 1.5 respectively. Mean prothrombin time increased from a pre-fracture mean of 12 in each group to 18.8 (group 1) 20.7 (group 2); 24.8 (group 3); 31.1 (group 4). Alveolar lavage samples taken at 0, 4 and 24 hours following injury indicated a progressive neutrophilia developing in each group with a count pre-fracture of 4.3 increasing to 55.75 (group 1); 40 (group2); 49 (group3) and 31.7 (group 4) by 24 hours following injury.

Discussion The effects of damage control techniques in this model appear to be a reduced stimulation of the extrinsic coagulation system. An additional embolic hit was detected secondary to intramedullary reaming and nail insertion. Localised lung inflammation seems to develop in all groups with no significant differences seen due to treatment.

Patients are increasingly demanding more (and better quality) information regarding the likely outcomes of THA surgery. Hip joint pain may be referred variably and widely in anatomical location and it has been unclear how reliably these pains can be relieved by arthroplasty.

193 patients undergoing primary unilateral Charnley THA were studied. Each patient was asked to indicate on a diagram where they were experiencing pain both preoperatively and at six months postoperatively. A scoring grid was superimposed for assessment. These two scores were compared with the Harris Hip Score, SF36 and satisfaction scores obtained at the same intervals. Comparisons were made between pre-operative and postoperative pain location and severity.

Preoperative pain is most often experienced in the groin (74% of patients), thigh (64%), knee (56%) and buttock (62%). Over 80% of pain in all zones is relieved by THA. However, the accepted assumption that groin and anterior thigh pains are the most reliably relieved is not borne out: pain is relieved in the leg and posterior thigh more reliably (in 97%, 93% and 100% cases respectively) than that in the groin (88%) or thigh (91%). Pain in the lower back is relieved in 81% of cases. Postoperative pain correlates closely with the postoperative SF36 and Harris Hip Score pain scores.

Postoperative dissatisfaction was most closely correlated with postoperative pain in the groin and buttock (p< 0.0001) and the anterior thigh (p< 0.05). 84% of patients would have the procedure again in the same circumstances, although 91% would recommend it to a friend or relative in the same situation.

THA is effective in relieving most pain around the hip. This is the case not only in the groin and anterior thigh which are often regarded as being highly specific for hip pain, but also in the lower back and leg. Postoperative dissatisfaction is highly significantly correlated with persisting pain in the groin, thigh and buttock.