Abstract

Over 8000 total hip arthroplasties (THA) in the UK were revised in 2019, half for aseptic loosening. It is believed that Artificial Intelligence (AI) could identify or predict failing THA and result in early recognition of poorly performing implants and reduce patient suffering.

The aim of this study is to investigate whether Artificial Intelligence based machine learning (ML) / Deep Learning (DL) techniques can train an algorithm to identify and/or predict failing uncemented THA.

Consent was sought from patients followed up in a single design, uncemented THA implant surveillance study (2010–2021). Oxford hip scores and radiographs were collected at yearly intervals. Radiographs were analysed by 3 observers for presence of markers of implant loosening/failure: periprosthetic lucency, cortical hypertrophy, and pedestal formation.

DL using the RGB ResNet 18 model, with images entered chronologically, was trained according to revision status and radiographic features. Data augmentation and cross validation were used to increase the available training data, reduce bias, and improve verification of results.

184 patients consented to inclusion. 6 (3.2%) patients were revised for aseptic loosening. 2097 radiographs were analysed: 21 (11.4%) patients had three radiographic features of failure.

166 patients were used for ML algorithm testing of 3 scenarios to detect those who were revised. 1) The use of revision as an end point was associated with increased variability in accuracy. The area under the curve (AUC) was 23–97%. 2) Using 2/3 radiographic features associated with failure was associated with improved results, AUC: 75–100%. 3) Using 3/3 radiographic features, had less variability, reduced AUC of 73%, but 5/6 patients who had been revised were identified (total 66 identified).

The best algorithm identified the greatest number of revised hips (5/6), predicting failure 2–8 years before revision, before all radiographic features were visible and before a significant fall in the Oxford Hip score. True-Positive: 0.77, False Positive: 0.29.

ML algorithms can identify failing THA before visible features on radiographs or before PROM scores deteriorate. This is an important finding that could identify failing THA early.

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Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Introduction

The Opera acetabular component (Smith & Nephew Ltd) shares many same design features with the Ogee (Depuy Int.). Differences are a malleable flange, instrumentation designed to improve cement pressurisation and the specifics of the UHMW-poly used.

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England.

The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action.

A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed.

The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465.

Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims.

Introduction

Traditionally it has been thought that the use of a small diameter femoral head in conjunction with a posterior surgical approach would result in a high rate of dislocation. We present the results of a consecutive series of 350 total hip replacements performed using a 22mm femoral head and a standard posterior approach, with prospective data collection.

Introduction

Varus malpositioning of femoral stems has been recognised as a poor prognostic feature with regard to loosening and failure of cemented composite beam implants, but there have been no published results of the long-term effect on taper-slip designs.

Introduction

Negative remodelling of the femoral cortex in the form of calcar resorption due to stress shielding and cortical hypertrophy at the level of the tip of the implant, due to distal load transfer, is frequently noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapers. The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The hoop stresses generated in the cement mantle are transferred to the proximal bone starting at the calcar, which should theoretically minimise stress-shielding and calcar resorption, as well as reducing distal load transfer, as signified by the development of distal femoral cortical hypertrophy.

Introduction

Traditionally the use of small diameter femoral head (22mm) with the posterior approach has been perceived as an increased risk of dislocation. We present this prospective study of 400 consecutive total hip replacements performed using a 22mm femoral head and the posterior approach.

Negative remodelling of the femoral cortex in the form of calcar resorption due to stress-shielding, and femoral cortical hypertrophy at the level of the tip of the implant due to distal load transfer, is frequenly noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapered components.

The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The implant is designed to subside within the femoral cement mantle utilising the cement property of creep, generating hoop stresses, which are transferred more proximally to the femoral bone, starting at the level of the medial calcar. The intention is to load the proximal femur minimising stress-shielding and calcar resorption, as well as reducing distal load transfer as signified by the lack of distal femoral cortical hypertrophy.

We present the results of a consecutive series of 500 total hip replacements using C-stem femoral components, performed between March 2000 and December 2005 at a single institution. Data was collected prospectively and all patients remain under annual follow-up by a Specialist Arthroplasty Practitioner. The operations were performed using a standard surgical technique with third generation cementing using Palacos-R antibiotic loaded cement.

500 arthroplasties were performed on 455 patients with an average age at the time of surgery of 68.3 years (23-92). There were 282 (62%) female and 173 (38%) male patients with osteoarthritis being the predominant diagnosis. 77 patients have died (73 hips) and the average duration of follow-up for the entire series is 81 months (52-124).

Only 2 femoral implants have been revised - one for deep sepsis and the other as part of a revision procedure for a loose acetabulum, although the femoral component itself was not loose. One implant is currently loose following a periprosthetic fracture treated by internal fixation, but none of the remaining implants demonstrates any progressive radiolucencies in any Gruen zones or any features suggestive of current or future loosening. Calcar rounding has been observed, but there have been no cases with obvious loss of calcar height and no cases of distal femoral cortical hypertrophy.

The C-stem femoral component has therefore performed well in clinical practice and the objective of eradicating negative bone remodelling has been achieved. The study is ongoing.

Cemented acetabular components continue to be used in more than half of the total hip replacements performed in the United Kingdom. The implants are relatively inexpensive but the results rely heavily on precise surgical technique, with restoration of the centre of rotation of the hip and the creation of an equal cement mantle with good pressurisation and penetration of the cement into the bone.

The Opera all polyethylene acetabular component was designed with a malleable flange, which could be independently pressurised, a long posterior wall to promote stability and instrumentation which ensured that pressurisation could be maintained throughout the curing process.

We present for the first time, the medium-term results of 409 consecutive cemented flanged Opera acetabular components performed in 374 patients.

247 operations were performed via a trochanteric osteotomy and 162 via a posterior approach, using multiple key holes, cement pressurisation and Palacos-R cement. Autograft was used in 32 cases.

Cemented femoral components were used in all cases. There were 241 Charnley stems with 22mm heads and 168 polished triple tapered C-stems (146 with 22mm heads and 22 with 26mm heads).

The average age at the time of surgery was 68.2 years (32–87) and the average duration of follow-up was 89 months (60–130). 54 patients (56 hips) died during the follow-up period.

The acetabulum was assessed using the zones of DeLee and Charnley, and the Hodgkinson classification.

There was one temporary femoral nerve palsy, two dislocations and 3 non-fatal pulmonary emboli.

Both components were revised in two hips for deep sepsis, and in two hips only the femoral implant was revised, one for a fractured stem and one for aseptic loosening, with the original acetabular components remaining in situ.

Of the remaining original acetabular components 6% have shown progressive radiological demarcation, none have migrated, but in two hips there is evidence of rapid wear and the development of osteolysis.

The use of polished femoral implants employing the taper-slip philosophy now dominates the cemented portion of the hip arthroplasty market in the United Kingdom. Despite this fact, there have been very few published or presented series reporting the medium to long-term results of double tapered implants and only one previously reported series looking at the results of the triple tapered stem.

We present the results of 500 consecutive polished triple tapered C-stem femoral components performed in 455 patients.

All operations were performed using a posterior appproach, with cemented all polyethylene acetabular components and the use of third generation femoral cementing techniques, restrictors, centralisers and Pala-cos-R cement.

There were 282 female patients (62%) and 173 males (38%). The average age at the time of surgery was 68.3 years (23 to 92), with an average duration of follow-up of 71 months (36 to 112). 47 patients (51 hips) died during the follow-up period at an average of 54 months (1–87).

There were 3 dislocations, 2 on one occasion and one twice, at an average of 4 years. There were 2 deep infections, one of which required revision, and 4 non-fatal pulmonary emboli. There were 3 undisplaced trochanteric cracks treated by cerclage wiring and 3 nerve palsies: 2 femoral (temporary) and one sciatic (permanent). There was only one case of significant heterotopic ossification (Brooker Class 4).

The stem was neutral in 89% of cases, varus in 7% and valgus in 4%. Subsidence within the cement mantle occurred in 79% of cases, with an average of 0.87mm. 9 stems subsided 2 to 4mm but all stopped at 2 years and there was no further subsidence thereafter.

One hip was revised for deep infection but none of the remaining implants demonstrated any progressive radiolucencies in any Gruen zones and none demonstrated any features suggestive of current or future loosening. There was no evidence of negative bone remodelling.

The data was collected prospectively and the study is ongoing.

We present the results of the polished triple tapered C-stem femoral component.

Prospective data was collected on a consecutive single surgeon series of 326 hip replacements in 293 patients performed between 2000 and 2005. All operations were performed via the posterior approach with a cemented all polyethylene acetabular component and third generation cementing of the femoral component.

There were 169 (58%) female patients and 124 (42%) males. There were 111 (34%) left sided procedures, 149 (46%) right sided and 33 bilateral (10%). Average age at time of surgery was 66.3yrs (25 – 89), with an average duration of follow-up of 50 months (12 – 78). The majority of the replacements were for osteoarthritis (271 hips 83%).

Nine patients (10 hips) died during the follow-up period at an average of 36 months (18 – 52), but outcome data was available on all patients and none were lost to follow-up. There was 1 temporary femoral nerve palsy, 2 non-fatal pulmonary emboli and 3 undisplaced trochanteric fractures. There were no dislocations, fatal pulmonary emboli, deep infections or revisions for any reason.

The stem was neutral in 90%, varus in 8% and valgus in 2%. There were no progressive radiolucencies in any Gruen zones and no distal femoral cortical hypertrophy. The average subsidence was 0.83mm, with none in 21%, < 0.5mm in 28%, 0.5 – 1mm in 41%, 1 – 2mm in 8% and 2 – 4mm in 2%.

There were no revisions and no stems demonstrated any features suggestive of current or future loosening. The study and prospective data collection is ongoing.

Many studies exist that assess intramedullary and extra-medullary fixation of these fractures, but few exist that compare the two. We performed a retrospective cohort study to compare the above implants in the management of subtrochanteric femoral fractures. 100 fractures in 95 patients were studied, with 47 in the recon nail group and 53 in the DCS group, with 33 male and 62 females, average age 68 years (16–98 years). Data was obtained by review of case notes and x-rays of all cases. The following information was obtained :- age, sex, energy/mechanism of injury, fracture classification (AO & Russell-Taylor, single observer), grade of surgeon, duration of surgery, ASA grading, co-morbidity (using Covinsky score), pre-operative mobility, postoperative mobility (using D’Aubigne & Postel score), mortality, intra-operative complications, post-operative complications, revision surgery/implant failure, follow-up and radiological assessment of reduction/implant position(single observer). Statistical analysis of the data was performed using chi-squared, Fisher’s, Mann-Whitney U and unpaired t-tests. Results showed no significant differences in co-morbidity, complications, mortality, duration of surgery, hospital stay, sex, surgical grade or pre-operative mobility. There were significant differences in age, fracture classification, radiological assessment of reduction/implant position, mechanism of injury and post-operative mobility. Overall 28-day mortality was 8%, post-op complications were seen in 54% and 19 cases required further surgery (detailed breakdown to be presented). Certain areas of bias were identified, in that the DCS had a higher number of complex fracture patterns, thus affecting post-op mobility, whereas the recon nail group had a higher proportion of pathological fractues.

Introduction: Fractures of the femoral stem component in total hip Arthroplasty have been a well documented complication. The incidence over recent years has decreased due to improvements in surgical technique and implant design and manufacture.

Methods/Results: We report two cases of femoral stem fracture. Both occurred in CDH stems from the C-stem system (Depuy International, Leeds, UK). These are the first reported fractures in this stem. Both patients were women weighing 83kgs and 98kgs at the time of fracture giving them BMI’s of 31 and 41 respectively. In both cases the BMI had increased since the time of operation.

Discussion: The design of the CDH stem is fundamentally different from the rest of the standard stems with absence of the medial strut. In addition to this factor, both stems fractured through the insertion hole which acted as a stress raiser. Finally both patients BMI’s were above 25. At the time of operation no weight limit was imposed on this prosthesis.

We conclude that if possible, a standard C-stem should be inserted but if a CDH stem is used attention to patients’ weight is paramount.

Introduction: The Opera Acetabular cup (Smith and nephew) was designed in North Manchester General and has been in use since 1997. The initial results were with multiple surgeons, different approaches and 2 different stems. We report the early results of the opera cup in primary hip replacements using the C-Stem.

Methods: This is a prospective radiological follow up of patients operated on between June 2000 and November 2004. 202 consecutive primary hip replacements were carried out using the Opera cup and a standard C-stem. All operations were performed by a single surgeon using the posterior approach. Initial and annual x-rays were studied and the following measurements taken: cup angle; radiolucent lines in the bone-cement interface of the acetabulum; heterotopic ossification; radiolucent lines or osteolysis in the femoral component and stem orientation.

Results: Full data is available in 166 hips performed on 149 patients. Average follow up is 37 months (12–65). 84 patients were female and 65 male. There were 56 left hip replacements, 76 right hip replacements and 17 were bilateral. 162 hips had an elite head whereas 4 had a ceramic head. Average cup angle was 44.6 degrees. 20 Cups had 0.5mm lucency in zone 1 of the acetabulum and 1 cup had 1mm lucency in zone 1. None were progressive. 14 patients had grade 1 heterotopic ossification 3 patients had grade 2. 1 stem was in valgus and 13 stems were in varus.

Complications were 1 calcar fracture and 1 greater trochanter fracture (both of which required circlage wires). There was also 1 temporary femoral nerve palsy which resolved in 3 months. There were no fatal PE’s, deep infections or dislocations. No hips have required revision.

Discussion: We conclude that in the short term the Opera cup is performing to the standard required by NICE.

Introduction: The C-stem total hip replacement system was devised in Wrightington in 1993 and represented the first triple tapered stem. There is little literature about the follow up outside of Wrightington and therefore we present our data on the C-Stem at a district general hospital.

Methods: This is a prospective radiological follow up of patients between March 2000 and November 2004, 250 primary hips were performed by a single surgeon using a posterior approach. Cemented all polyethylene cups were used. Initial and annual x-rays were reviewed and the following measurements were recorded: cup angle; radiolucent lines in the bone-cement interface of the acetabulum; heterotopic ossification; stem subsidence, radiolucent lines or osteolysis in the femoral component and stem orientation.

Results: Data is available on 206 hips performed on 185 patients. 107 patients were female and 78 patients were male. 72 were left sided, 92 were right sided and 21 were bilateral. The average age was 66yrs (25–89). Average follow up was 41 months (12–68). The average cup angle was 44.7 degrees. 24 patients had 0.5 mm lucencies in zone 1 of the acetabulum and 1 patient had 1mm lucency in zone 1. No lucencies were progressive. There were no lucencies in any of Gruens’s zones. 18 patients had Grade 1 heterotopic ossification, 2 Grade 2 and 1 Grade 4. 17 stems were in varus and 1 stem in valgus. Average stem subsidence was 0.83mm.

Complications were 1 fractured greater trochanter wired intra-operatively and 1 femoral nerve palsy which resolved in 3 months. There were no PE’s, dislocations or deep infections. No hip replacement has required revision.

Discussion: We conclude that at a maximum follow up of 5.5 years the C-Stem is performing to standards required by NICE and is on course to achieve the benchmark of 10% revision at 10 years.

This is a prospective study to determine if we could identify patients who may benefit from preoperative catheterisation in lower limb arthroplasty.

211 consecutive patients undergoing total hip and knee arthroplasty were recruited. There were 131 female (62%) and 80 male (32%), the mean age (+−1 S.D.) was 68+−12 years old. Patients’ demographic details and pre-operative urinary symptoms were recorded. Previous urological surgery and past history of urinary catherisation were also documented. The anaesthetist who was blinded from the study selected the type of anaesthesia and the post-operative analgesia regime. All patients were required to produce mid-stream urine sample before surgery and at post-operation. Urine tract infection was confirmed on a positive microbiological culture. Regression analysis was used to assess various co-variables to identify the high-risk groups.

35 female (56%) and 27 male (44%) were catheterised, the mean age (+−1 S.D.) was 72+/−14 years old. The frequency of catheterisation was unrelated to the surgical procedure, the type of anaesthesia or the postoperative pain control regime. Age over 65 years old and nocturia were significant indicators for urinary catheterisation (p< 0.05). Patients with urinary incontinence and nocturia were strong determinant for urinary catheterisation (p< 0.03). Males over the age 65 years with a past history of urinary catheterisation (p=0.037) were more likely to be catheterised than females of the same group (p=0.947). This has become more evidential if patients have coexisting urinary incontinence and nocturia (p=0.005). Females over the age of 65 years with urinary incontinence were also significant (p=0.013).

The sensitivity for urinary catheterisation in patients over the age of 65 years with previous history of catheterisation, urinary incontinence or nocturia was 89.7%. This group of patients would benefit from pre-operative urinary catheterisation.

To assess the cost involved and whether orthopaedic patients with Methicillin-resistant Staphylcoccus aureus (MRSA) infections were being managed according to national guidelines, retrospective survey of all MRSA infections over a 26 months period was performed. Demographic details and risk factors were identified. Infection control measures were compared with national guidelines. Total length of hospital stays, treatments received and cost were noted.

In total, 78 patients were diagnosed with a MRSA infection (31 male and 47 female) with a mean age 66.4 years +/− 20.8 SD. MRSA infections occurred in 75 (97%) trauma patients and in 2 (3%) elective patients. MRSA infections were isolated from wounds in 62 patients, others sites include sputum, blood, urine and skin colonization. The average time of diagnosis after admission was 20.6 days +/− 16.6 SD. Major risk factors were internal fixation of fractures (97%), previous antibiotics (97%), nursing home residents and hospital transfers (50%). Normal national guidelines were followed in 86% of the cases. Antibiotics were used in 67 patients after microbiological confirmation; this additional cost exceeded £19,000. The mean hospital stay was 50.7 days and the cost of hospitalization per patients exceeded £19,700 (£388.60 per day). Incidence of MRSA infection in trauma and elective patients were 2.4% and 0.1% respectively. Infection control policies were strictly followed in 86% of the cases. Long hospitalization and antibiotics were a significant risk factor for developing MRSA infections. Considering the low incidence of MRSA infection in elective surgery, segregation of trauma and elective patients is an important measure in reducing the incidence and cost of MRSA infections. Substantial saving can be achieved with firmer antibiotics policies.

Do patients’ recollections of disease severity following joint replacement surgery accurately reflect their pre-operative disability? Oxford Knee score questionnaires were sent to 100 patients who had undergone primary knee replacement surgery between January 1998 and July 2000.They were asked to complete these in a manner reflecting their pre-operative disability. The results were then compared with actual scores completed by the same group of patients prior to their surgery. The response rate was 78%.The mean pre-operative score was 45 compared to the recall score of 46.9. The difference was not significant (p=0.77).We believe that recall of disability using a simple knee score is a reliable method of assessing pre-operative disability.

There is a legal and ethical obligation to gain informed consent before treatment commences. A number of bodies have issued guidelines for obtaining consent and these include the Department of Health, the GMC, The Royal College Surgeons of England, and the B.O.A. For a patient to give their informed consent to surgery they must receive sufficient information about their illness, proposed treatment and its prognosis. There are no specific guidelines regarding joint replacement. With this in mind a retrospective case note study was undertaken involving 100 patients who had undergone a hip replacement. Noting the documented discussion at all stages of patient contact.Fifty percent of patients had been seen and listed in the Outpatients by a Consultant, 25% were discussed with the Consultant responsible and the remainder were listed without Consultant input. In only 33 % of cases were any specific risks recorded. This had fallen to 4% on their visit to pre operative assessment clinic. All the consent forms were completed at the time of admission for surgery. Forty percent of these on the day of surgery. The majority were completed by SHOs (58%), while only 4% were completed by consultants. None of the forms noted the lead surgeon. All the consent forms noted some frequently occurring risks. However there was a large variance in the details recorded. The study highlights that the majority of complications are only documented on the consent form, with little note of the dialogue leading up to it. It is also apparent that there is no agreement as to what represents a significant or frequent complication.

This review raises a number of important issues. There needs to be a national standardisation of the process of consent. We propose the introduction of a specific consent form for hip replacements that provide improved documentation of the standardised risks involved. This should also include guidelines regarding prosthesis choice, surgical approach and the extent of trainee involvement. In addition we would also suggest there is a need to improve sequential documented discussion up to the point of surgery and introduce specific training for juniors carrying out consent.

Introduction & aims: Quadriceps muscle wasting is common in patients with osteoarthritis (OA) of the hip and knee. Previous studies,using ultrasound and performing biopsies, have demonstrated quadriceps muscle fibre atrophy. Thigh girth measurements are quoted in textbooks as a means of quantitatively assessing muscle bulk. This study has looked at these measurements in patients with hip and knee OA to see if these measurements are useful.

Method: 87 patients (mean age 62, range 36–87) with a diagnosis of OA were seen in the pre-assessment clinic. 47 were awaiting total hip replacement (THR) and 40 were awaiting total knee replacement (TKR).All were awaiting primary arthroplasty and had not had previous joint surgery. Thigh girth measurements were taken at 2 points corresponding with one-third and two-thirds of the length between the anterior superior iliac spine and the tibial tuberosity. These measurements were taken for both thighs. The observed differences were analysed with normal probability plots and paired Student’s t-tests.

Results: No significant difference in thigh girth could be detected in patients awaiting total knee replacement. Girth was significantly reduced in the thigh on the side of planned THR. This difference was apparent when measured both proximally and distally.

Conclusion: Measurements of thigh girth were not useful indicators of quadriceps wasting in patients awaiting TKR. Patients awaiting THR should have thigh girth measured, those with reduced thigh girth on the side of planned arthroplasty may have quadriceps atrophy and can then be referred for physiotherapy prior to surgery.

Aims: To investigate whether blood transfusion practice in primary total knee replacement (TKR) was being managed appropriately, and to assess the cost effectiveness of pre-operative autologous donation (PAD). Methods: A retrospective survey of blood transfusion practice was conducted for all TKR. The unit has an established PAD service with over 60% uptake for suitable candidates. An analysis of all pre-operative and post-operative haemoglobin concentrations (Hb) was performed. Using Hb concentration of 8 g/dl or 9 g/dl as the transfusion criteria, the total units of blood used, saved or discarded was calculated. Results: 174 TKR were performed, 84 (48%) patients were transfused. 52 patients (117 units) received allogenic blood, 35 patients (61 units) received PAD blood, 8 patients received both. 60 units (50%) of PAD were discarded. Using a level of Hb of 8 g/dl, 46 patients (96 units) would have received allogenic blood, 30 patients (51 units) would have received PAD blood and 7 patients both. 70 units (58%) of PAD would have been discarded. Using a level of Hb of 9 g/dl, 35 patients (69 units) would have received allogenic blood, 22 patients (36 units) would have received PAD blood and 6 patients both. 85 units (70%) of PAD would have been discarded. If the transfusion threshold used were < 8 g/dl and < 9 g/dl, the potential saving was estimated at approximately £9578 and £6884 respectively. Conclusions: PAD service is considerably more expensive than allogenic blood. With high percentages of PAD being discarded, the service is not cost effective. Substantial saving can be achieved with a þrmer transfusion policy for post-operative patients.

Aim: The aim of this research was to assess the difference in the observed tibiofemoral axis between long leg and short AP films of the knee.

Method: 20 patients who were undergoing primary total knee replacement, and had had no previous surgery on the affected limb were x-rayed using the a long leg cassette to include both the hip and ankle joints. A special screen was constructed to obscure all the x-ray except for a field, the size of a standard AP x-ray of the knee. The tibiofemoral angle was measured by two independent observers first on the short film and then on the long leg film.

Results: Our results have shown that the short leg film consistently overestimates the true tibiofemoral angle. Intraobserver correlation is also better when comparing the long leg film rather than the short film.

Conclusion: Measurement of the tibiofemoral or anatomical axis of the knee is best performed using long leg films, as this appears to give more consistent and reproducible results.

Cross match practice for patients with femoral neck fractures continue to cause concern due to a failure of compliance to the existing protocols. We addressed this issue by conducting a number of studies over three years and we report the summation of the studies and demonstrate the reasons for the poor compliance. We provide a simple and effective protocol that has helped reduce preoperative cross matching of femoral neck fractures from 71% to 16.7% two years after its introduction.

Study 1

Retrospective review of the cross-match practice for 240 femoral neck fractures and reviewed the changes in pre-operative and post-operative haemoglobin levels and association with surgical procedure.

Study 2.

Postal questionnaire of 129 anaesthetic and orthopaedic trainees assessing the perceived cross-match requirements of patients with femoral neck fractures based on preoperative haemoglobin values between 8–13g/dl. In addition reviewed the source of trainees perceptions and practice

Study 3

Review of the efficiency of the cross-match protocol two years after its introduction Results

Study 1

71% patients with femoral neck fractures were cross-matched at admission but only 29% of the patients were subsequently transfused. From the 384 units of blood ordered at admission 230 were returned unused. Inter-trochanteric fractures had a mean blood loss of 3.1g/dl (range 1.5–7.2g/dl) following surgery in comparison to a mean loss of 1.7g/dl (0.9–3.4g/dl) for patients with displaced subcapital fractures

Study 2

Orthopaedic trainees at all levels of training requested more blood then their anaesthetic counterparts for patients with femoral neck fractures. There was misconceptions regarding blood loss following surgery amongst all trainees and only 14.3% trainees used existing literature to guide their cross-match practice where as 53.4% devised protocols based on their own or colleagues’ experience.

Study 3

Cross-match protocol was working effectively. Only 16.7% of the patients with femoral neck fractures were cross-matched on admission.

Conclusion

Cross-match recommendations fail to influence trainees. In order to address this we produced a protocol that does not rely on orthopaedic trainees. The haematology MLSO provides the appropriate amount of preoperative blood for the patient based on our finding of blood loss of different fracture patterns and the patients’ preoperative haemoglobin level. Our results show our protocol is still effective two years following its introduction despite numerous changes in trainees during this period.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared test.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients and the production of pre-operative literature.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared tests on SPSS.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients, production of preoperative literature and for improving the service we offer to our patients.