We prospectively assessed the efficacy of a ceramic-on-metal (CoM) hip bearing with uncemented acetabular and femoral components in which cobalt­–chrome acetabular liners and alumina ceramic heads were used.

The cohort comprised 94 total hip replacements (THRs) in 83 patients (38 women and 45 men) with a mean age of 58 years (42 to 70). Minimum follow-up was two years. All patients had pre- and post-operative assessment using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Oxford hip score and Short-Form 12 scores. All showed a statistically significant improvement from three months post-operatively onwards (all p < 0.001).

After two years whole blood metal ion levels were measured and chromosomal analysis was performed. The levels of all metal ions were elevated except vanadium. Levels of chromium, cobalt, molybdenum and titanium were significantly higher in patients who underwent bilateral THR compared with those undergoing unilateral THR (p < 0.001). Chromosomal analysis demonstrated both structural and aneuploidy mutations. There were significantly more breaks and losses than in the normal population (p < 0.001). There was no significant difference in chromosomal aberration between those undergoing unilateral and bilateral procedures (all analyses p ≥ 0.62).

The use of a CoM THR is effective clinically in the short-term, with no concerns, but the significance of high metal ion levels and chromosomal aberrations in the long-term remains unclear.

Cite this article: Bone Joint J 2013;95-B:1040–44.

INTRODUCTION

Tranexamic Acid (TA) has been shown to decrease peri-operative bleeding in primary Total Knee Replacement (TKR) surgery. There are still concerns with regards to the increased risk of thromboembolic events with the use of TA. The aim of this study was to assess whether the use of pre-operative TA increased the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in TKR.

Introduction: Reinfusion drains are used to minimise the need for allogenic blood transfusion, and its potential complications. Tranexamic acid {TA} is an antifibrinolytic agent that is used to decrease blood loss in total knee arthroplasty surgery. The effect of TA on reinfusion volume of drained blood has received little attention. The aim of our study is to measure the effect of TA on reinfusion volumes in primary total knee replacement {TKR}.

Methods: A cohort of consecutive patients undergoing primary total knee replacement between November 2006 and January 2008 were studied. Each patient was operated upon by the same surgeon, and had the same pros-thesis inserted. Patients operated upon before June 2007 did not receive TA but had reinfusion drains, while those who underwent surgery after June 2007 received TA along with the reinfusion drain. We measured pre and post operative haemoglobin {Hb}, drainage volume and reinfusion volume. The need for allogenic blood transfusion was recorded. TA and non TA groups were compared.

Results: Seventy patients were included in the study. There was no significant difference between the TA and non TA groups in pre operative Hb {13.2, 13.1g/dl} or post operative Hb {10.95, 10.9}. There was a significantly lower drainage volume {250 v 600ml} and subsequent reinfusion volume {100 v 465ml} in the TA group versus non TA groups respectively. There were no cases of thromboembolism or allogenic blood transfusion in either group.

Conclusion: Tranexamic acid significantly decreased post operative blood loss and subsequent reinfusion volumes in TKR. TA and reinfusion drains greatly decrease the demand for allogenic blood transfusion. Drainage volume is so low when TA is used in routine primary TKR, that the need for reinfusion drains is questionable. TA is cost-effective compared to reinfusion drains in TKR.

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts for TKR, but the efficacy of a sciatic nerve block as an adjunct to a femoral nerve block is controversial. The aim of this study was to compare femoral with femoral and sciatic nerve blocks in postoperative pain management of patients undergoing total knee arthroplasty (TKA).

Methods: 42 patients were involved in the study. 20 patients received only a femoral nerve block, consisting of 20ml of 0.5% Chirocaine and 22 patients received femoral and sciatic nerve blocks, consisting of 20ml of 0.375% Chirocaine for the femoral nerve and 10ml of 0.5% Chirocaine for the sciatic nerve. The primary outcome measures used were visual analogue scale (VAS) scores for pain at 24 hours, 48 hours and 72 hours after the surgery, opiates consumption post-operatively and PCA use. The secondary outcomes were post-operative nausea and vomiting, sensory deficit, quadriceps contraction, straight leg raise, knee flexion, independent mobility and discharge from the hospital.

Results: The results showed no difference in opiate consumption, PCA use, independent mobility and time of discharge from the hospital between the two groups.

Conclusion: The study shows that the addition of a sciatic nerve block to the femoral nerve block does not provide additional benefits.

Between 1980 and 2000, 63 support rings were used in the management of acetabular deficiency in a series of 60 patients, with a mean follow-up of 8.75 years (2 months to 23.8 years). There was a minimum five-year follow-up for successful reconstructions. The indication for revision surgery was aseptic loosening in 30 cases and infection in 33. All cases were Paprosky III defects; IIIA in 33 patients (52.4%) and IIIB in 30 (47.6%), including four with pelvic dissociation. A total of 26 patients (43.3%) have died since surgery, and 34 (56.7%) remain under clinical review. With acetabular revision for infection or aseptic loosening as the definition of failure, we report success in 53 (84%) of the reconstructions. A total of 12 failures (19%) required further surgery, four (6.3%) for aseptic loosening of the acetabular construct, six (9.5%) for recurrent infection and two (3.2%) for recurrent dislocation requiring captive components. Complications, seen in 11 patients (18.3%), included six femoral or sciatic neuropraxias which all resolved, one grade III heterotopic ossification, one on-table acetabular revision for instability, and three early post-operative dislocations managed by manipulation under anaesthesia, with no further instability.

We recommend support rings and morcellised bone graft for significant acetabular bone deficiency that cannot be reconstructed using mesh.

We report a case of local compression-induced transient femoral nerve palsy in a 46-year-old man. He had previously undergone surgical release of the soft tissues anterior to both hip joints because of contractures following spinal injury. An MRI scan confirmed a synovial cyst originating from the left hip joint, lying adjacent to the femoral nerve. The cyst expanded on standing, causing a transient femoral nerve palsy. The symptoms resolved after excision of the cyst.

Aim: A retrospective study to analyse the treatment of paediatric diaphyseal forearm fractures over the preceding 6 years and to assess if there was any difference in outcome between plate and elastic stable intra-medullary nailing (ESIN).

Material and Methods: Between January 1997 and December 2002, 144 unstable fractures required surgical fixation. 59 patients were treated with both-bone plate fixation, 55 patients were treated with single-bone plate fixation and 30 patients were treated with ESIN.

The mean age of surgery was approximately 12 with peaks at age 8 and 13 years.

In the plate group, 70% to 80% were undertaken by the SpRs and in the nailing group, approximately 50% were undertaken by staff grades; 30% by Consultants and 20% by SpRs.

Results: Between each group there was no difference in time spent in plaster, clinic attendance, time to clinical union and time to restoration of normal movements. On radiographic reviews, single-bone plate fixation patients united quicker than the both-bone plate fixation or ESIN groups. Average anaesthetic times became more prolonged from single-bone to ESIN to both-bone plate fixation.

Compound fractures were approximately 10% in both groups. There were hyper-trophic scars in approximately 10% in the plate group and 3% in the nail group. There were 3 compartment syndromes in the plate group and 2 compartment syndromes in the nail group.

In the plating groups, there was a higher rate of peri-prosthetic fracture, mal-union, hyper-trophic scarring, infection and neuro-vascular complications.

Conclusion: ESIN is superior to plating in relation to surgical complications. It is therefore recommended that elastic stable intra-medullary nailing should be used for displaced paediatric diaphyseal forearm fractures.