Aims: To determine the effect of a simple, user-friendly algorithm developed as a guidance for reducing the need for allogeneic blood transfusions in total hip and knee arthroplasty. Methods: Allogeneic blood use in elective primary hip and knee arthroplasty was prospectively determined in an observational study, with 229 consecutive patients assessed before (November 1998 to September 1999) and 262 consecutive patients assessed after the implementation of a simple one-page algorithm in a Swiss orthopaedic tertiary care centre (October 1999 to October 2000). The algorithm was widely disseminated and placed in all charts of patients undergoing total hip or knee arthroplasty and handed out to any of the orthopaedic centreñs physicians and nurses from October 1st 1999 onwards. The medical staff was required to follow the algorithm for all medical decision making related to allogeneic blood transfusion. Results: Patients before and after the implementation of the algorithm were well matched. The mean number of units of allogeneic blood transfused per patient was reduced from 0.88 units to 0.43 units (p< 0.0001 by Mann-Whitney test). 80 out of 229 patients received allogeneic blood transfusions before, and 49 out of 262 after implementation of the algorithm (odds ratio 0.43, 95% CI 0.28 to 0.65, p< 0.001). There was also a highly signiþcant decrease in the mean number of units of autologous blood donations, from 0.56 to 0.13 units (p< 0.0001). There was only one ischaemic event in each group. Conclusions: Allogenic blood transfusions in primary hip and knee arthroplasty may be reduced by implementing a simple user-friendly algorithm. Our results need to be conþrmed in a large-scale cluster-randomised trial.

Aims: Long-term quality assessment of intramedullary reaming of chronic osteomyelitis in long bones. Methods: Forty-three patients with forty-four chronic, consecutive, diaphysal osteomyelitis in long bones where treated by intramedullary reaming. Charts where retrospectively evaluated and a follow-up investigation took place. Results: The mean follow-up for thirty-four surviving patients was 117 months (84–178 months). At the follow-up, twenty-three patients work full-time, three have a reduced ability to work, and eight have retired. Twenty-seven patients have no pain, seven have mild pain, and one case has moderate pain during working or walking. Nine patients died during the follow-up. In thirty-seven cases (83%) osteomyelitis never reoccurred at the time of death or follow-up. Five patients needed revisions. One þstula closed spontaneously and one patient didnñt want a revision. Conclusions: The reaming technique as well as an interdisciplinary antibiotic therapy seems to inßuence the outcome. In attendance to the described technique, intramedullar reaming after post-traumatic or haematogenous osteomyelitis of the diaphysis of long bones proves to be a valuable treatment procedure with a local recurrence of 7% within þve years and 23% within fourteen years.

Aims: We have been alerted due to a high and early failure rate in total hip arthroplasties using metal-on-metal (Metasul?) bearings. Investigation on retrieved bearings at revision surgery should lead us to causes for early failures. Methods: 135 primary total hip arthroplasties in 118 patients (28 women and 90 men) with Metasul¨ bearing were implanted between 1992 and 1998. The mean age at implantation was 55 years (range, 29 to 84). In 105 cases a cementless MŸller SL cup and in 30 cases a MŸller Reinforcement Ring was used. Twelve out of 105 cases with a þne blasted SL cup needed a revision surgery after 34.9 months (range, 13 to 59). Qualitative histology was performed in all cases, quantitative metal analysis took place in two cases. The wear rate of the heads and their insert was measured and compared to former studies. Bony cylinders taken from the acetabular roof prior to primary implantation were histologically analyzed and compared to cup migration studies (EBRA). Results: Four cups and seven cemented titanium stems with tight cups were loose. In one case with polyarthritis both components had to be replaced. In one patient with cup loosening an impingement between neck and cup was found. In two patients histology showed diminution of bone-stock and in two cases no bony integration was observed. Conclusions: From twelve revision cases, we found only one where the metal-metal bearing is clearly responsible for the revision surgery. Metal-on-metal articulation seems to be promising if the component orientation is correct.