Background. To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury. Study design. A retrospective analysis of the prospectively recorded Trauma Registry data (TARN) from 1989 to 2003. Methods. Patients were divided into groups UFi (isolated unilateral femur injury),BFi (isolated bilateral femur injury) and UFa and BFa if an associated injury was present. Data collected for each patient included age, Injury Severity Scores, Glasgow Coma Scale, mortality, physiological parameters, the timing and extent of prehospital care, the time to arrival at the hospital, initial treatments, time to and type of surgery, length of ICU and hospital stay. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. Results. Patients in group BFa had a significantly higher ISS (23 vs 9),reduced GCS (12 vs 15) and increased mortality rate (31.6% vs 9.8%) than patients in group BFi. Group BFa patients had an increased number of associated injuries than group UFa. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and mortality. However bilateral fracture, even in isolation significantly increased the odds of mortality by 3.07(1.36-6.92). Intramedullary nailing (IMN) was the method of fracture fixation associated with the lowest patient mortality overall. However, when assessing patient mortality in the BFa group with an ISS of more than 40, three other fracture fixation regimens were associated with a lower mortality rate than the IMN group. Conclusions. The increase in mortality with bilateral femoral fractures is more closely associated with the presence of associated injuries and poor physiological parameters than to the presence of the bilateral femoral fracture alone. However contrary to ISS scoring the latter does convey a significant additional risk of mortality. The presence of bilateral femoral fractures should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential

The emergence of patient specific instrumentation has seen an expansion from simple radiographs to plan total knee arthroplasty (TKA) with modern systems using computed tomography (CT) or magnetic resonance imaging scans. Concerns have emerged regarding accuracy of these non-weight bearing modalities to assess true mechanical axis. The aim of our study was to compare coronal alignment on full length standing AP imaging generated by the EOS acquisition system with the CT coronal scout image. Eligible patients underwent unilateral or bilateral primary TKA for osteoarthritis under the care of investigating surgeon between 2017 and 2022, with both EOS X-Ray Imaging Acquisition System and CT scans performed preoperatively. Coronal mechanical alignment was measured on the supine coronal scout CT scan and the standing HKA EOS. Pre-operative lower limb coronal alignment was assessed on 96 knees prior to TKA on the supine coronal scout CT scan and the standing HKA EOS. There were 56 males (56%), and 44 right knees (44%). The mean age was 68 years (range 53-90). The mean coronal alignment was 4.7 degrees (SD 5.3) on CT scan and 4.6 degrees (SD 6.2) on EOS (p=0.70). There was a strong positive correlation of coronal alignment on CT scan and EOS (pearson. 0.927, p=0.001). The mean difference between EOS and CT scan was 0.9 degrees (SD 2.4). Less than 3 degrees variation between measures was observed in 87% of knees. On linear regression for every 1° varus increase in CT HKA alignment, the EOS HKA alignment increased by 0.93° in varus orientation. The model explained 86% of the variability. CT demonstrates excellent reliability for assessing coronal lower limb alignment compared to EOS in osteoarthritic knees. This supports the routine use of CT to plan TKA without further weight bearing imaging in routine cases

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement). Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair. A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group. Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed

Although the impact of sexual difficulties on quality of life in patients with hip osteoarthritis has been documented in previous literature, recent research has shown that surgeons rarely discuss this sensitive topic with patients. The purpose of this study was to develop an educational tool to address common questions that patients may have regarding returning to sexual activity following their total hip arthroplasty (THA). The study was conducted in two phases. In Phase 1, patients who underwent a THA between 2013–2017 at a single centre were retrospectively identified and sent an anonymous online survey. This survey was aimed at assessing patient-specific concerns regarding whether they would have liked to receive information about returning to sexual activity, what information they would have liked to know and how they would have liked to receive this information. An educational tool was developed based on the findings of Phase 1. In Phase 2, prospective patients who were scheduled for a unilateral or bilateral THA were provided with the educational tool prior to their surgery. A questionnaire was administered to evaluate the effectiveness of this educational tool. Descriptive statistics and chi-squared tests were used for data analysis. In Phase 1, the overall response rate was 34.7% (n = 58/167). Out of the total respondents, 51.7% indicated an interest in receiving information on when to return to sexual activity following a THA. Patients selected an informational pamphlet as the most desired method of receiving information (p = .044). In Phase 2, the response rate was 54.5% (n = 30/55). Overall, 90% of patients felt that the pamphlet addressed all their concerns, and 93.3% felt they were provided with adequate information on how they could get more information. The pamphlet addressed questions regarding when it was safe to resume sexual activity following a THA, what positions were safe, and the associated risks. Individuals undergoing a THA are modestly interested in receiving information regarding when to return to sexual activity following their surgery, especially those who are sexually active preoperatively. This educational pamphlet may be useful in routine clinical practice in addressing concerns regarding returning to sexual activity. Understanding patients' goals and expectations for their postoperative course may help surgeons provide a more comprehensive approach to patient care

Background. Total hip arthroplasty (THA) is a highly successful procedure, yet access to arthroplasty is limited in many developing nations. In response, organizations around the world have conducted service trips to provide international arthroplasty care to underserved populations. Little outcomes data are currently available related to these trips. We present a 1-year follow up. Methods. We completed an arthroplasty service trip to Brazil in 2017 where we performed 46 THAs on 38 patients. Patient demographic data, comorbidity profile, complication data, and pre- and postoperative Modified Harris Hip Score (mHHS), PROMIS Short Form Pain (SF-Pain), PROMIS Short Form Physical Function (SF-Function), and HOOS Jr scores were collected. Outcomes were collected postoperatively at 2, 6, and 12 weeks and 1 year. A multivariate regression analysis was performed to identify associations between patient factors and 12-week outcomes. Results. The mean patient age was 48.8 years. 47% were female. 30 patients had a unilateral THA and 8 had bilateral simultaneous THA (table 1). 61% of patients had a preoperative diagnosis of osteoarthritis (OA), 13% avascular necrosis, 13% post-traumatic OA, 8% developmental hip dysplasia, and 5% rheumatoid arthritis. Mean pain duration was 1–5 years for 45% of patients and >5 years for 55% of patients. The mean mHHS, HOOS, PROMIS SF-Pain and PROMIS SF-Function all improved significantly compared to baseline at 2, 6, 12 weeks and 1 year post-operatively (table 2, figure 1 & 2). At 1 year, only 11 of 38 patients (29%) were reachable by phone for follow up. The mobile phones were out of service for 27 of 38 patients (71%). Multivariate regression analysis did not reveal any associations at 12 weeks between patient reported outcomes and age, gender, pain duration, preoperative diagnosis or unilateral versus bilateral surgery (table 3). Conclusion. We found that patients in a developing country benefitted significantly from THA when performed by a visiting surgical team. Outcomes were similar to those seen in the United States. Of those that could be contacted, outcomes were stable at 1 year. This study highlights the difficulty of following patients in developing countries once they leave the hospital. Methods need to be developed to assure that the outcomes of these potentially valuable procedures can be determined. We are currently establishing the capability of using email and smart phone applications linked through email addresses to improve follow up on future missions

INTRODUCTION. Metal-on-metal hip resurfacing arthroplasty (MoMHRA) is a surgical option in the treatment of end-stage hip disease. The measurement of systemic levels of metal ions gives an insight into the wear occurring and is advocated by regulatory bodies as routine practice in the assessment of resurfaced hips. However, the acceptable upper levels of Chromium (Cr) and Cobalt (Co) ions concentration with clinical significance still have to be established. The aim of this study is to address this issue in unilateral and bilateral resurfaced hips. METHODS. 453 patients with unilateral MoMHRA and 139 patients with bilateral MoMHRA at >12 months postoperative were retrospectively identified from an independent hip specialist's database. Routine metal ion levels were measured at last follow-up (ICPMS protocol). Radiological assessment included measurement of acetabular component orientation using EBRA, calculation of contact patch to rim (CPR) distance, and evaluation for any adverse X-ray findings. The cohort was divided into the well functioning group (Group A) and the non-well functioning group (Group B). A well functioning resurfacing gad to fulfil all of the following criteria (bilateral patients had to fulfil criteria for both hips): no patient reported hip complaints, no surgeon detected clinical findings, HHS> 95, CPR distance> 10mm, no abnormal radiological findings and no further operation scheduled. Upper levels (acceptable limits) of Cr/Co were considered to be represented by the top margin of the box-whisker plot [upper limit = 75. th. quartile value + (1.5 x interquartile range)] in Group A. RESULTS. 251 unilateral MoMHRAs patients (55%) and 58 patients with bilateral MoMHRAs (42%) comprised Group A. The majority of males were in Group A compared to the majority of females who belonged in Group B (p<0.001); subsequently Group A patients had bigger size components (p<0.001). Unilateral Group A [Cr: 2.0 µg/l (SD: 1.5)/ Co: 1.8µg/l (SD: 1.2)] patients had significantly lower ions than Group B [Cr: 7.3µg/l (SD: 17.3)/ Co: 6.6µg/l (SD: 18.1)] patients (p <0.001). Similarly, Group A bilateral patients [Cr: 3.8µg/l (SD: 2.7)/ Co: 2.8µg/l (SD: 1.9)] had significantly lower ions that Group B [Cr: 10.7µg/l (SD: 16)/ Co: 8.5µg/l (SD: 15.8)]. The upper levels (safe were: Cr: 4.6µg/l / Co: 4.0µg/l for unilateral MoMHRAs and Cr: 7.4µg/l / Co: 5.0µg/l for bilateral MoMHRAs. Unilateral MoMHRAs had significantly higher ion levels compared to bilateral patients (p <0.001). Sensitivity and specificity of these upper levels in predicting poor function were respectively 25% and 95% for Cr and 22% and 96% for Co. DISCUSSION. The findings of this study suggest that both unilaterally and bilaterally resurfaced patients with well functioning implants have low metal ion levels with upper levels of Cr: 4.6µg/l / Co: 4.0µg/l for unilateral MoMHRAs and Cr: 7.4µg/l / Co: 5.0µg/l for bilateral MoMHRAs These results indicate that the upper acceptable limit of metal ion levels in resurfaced hips is lower than the previously MHRA recommended threshold, however the study was conducted with very low tolerance for what was considered a clinically problematic hip. Well-functioning bilateral resurfacing have higher ion levels compared to well-functioning unilateral resurfacing

Background. Total hip replacement is a highly successful procedure, yet access to arthroplasty is limited in many developing nations. In response, organizations in the United States have conducted service trips to provide international arthroplasty care to underserved populations. Little outcomes data are currently available related to these trips. We aimed to assess patient outcomes following total hip arthroplasty performed on a surgical mission trip. Methods. We completed an arthroplasty service trip to Brazil during which we performed 46 total hip arthroplasties (THA) on 38 patients. Patient demographic data, comorbidity profile, complication data, and pre- and postoperative Modified Harris Hip Score (mHHS), PROMIS Short Form Pain (SF-Pain), PROMIS Short Form Physical Function (SF-Function), and HOOS Jr scores were collected. Baseline and final follow-up scores were compared. In addition, we utilized a novel questionnaire that was designed to determine outcomes most relevant to patients receiving joint replacements in developing countries. A multivariate regression analysis was performed to identify associations between patient factors and outcomes. Results and Discussion. The mean patient age was 48.8 years, and 47% were female. 30 patients had a unilateral THA and 8 had bilateral simultaneous THA. 61% of patients had a preoperative diagnosis of osteoarthritis (OA), 13% avascular necrosis, 13% post-traumatic OA, 8% developmental hip dysplasia, and 5% rheumatoid arthritis. Mean pain duration was 1–5 years for 45% of patients and >5 years for 55% of patients. The mean mHHS, HOOS, PROMIS SF-Pain and PROMIS SF-Function all improved significantly compared to baseline at 2 and 6 weeks post-operatively. Multivariate regression analysis did not reveal any associations between patient reported outcomes and age, gender, pain duration, preoperative diagnosis or unilateral versus bilateral surgery. Subjective questionnaires at 12 weeks postoperatively revealed that surgery met expectations for 94% of patients; 97% of patients had as much pain relief as they expected; 45% of patients had no physical limitations; 82% of patients were not taking any medications for their hip (18% used occasional NSAIDs); 82% of patients gained new independence at home; and 97% felt their overall quality of life improved significantly. Two patients had postoperative periprosthetic femur fractures requiring an ORIF. One patient had a DVT requiring 6 months of anticoagulation. Conclusion. We found that patients in a developing country benefitted significantly from total hip arthroplasty when performed by a visiting surgical team, with acceptable complication profiles. Validated legacy outcome measures show improvements in pain and function after THA similar to those observed in patients in the United States. Additionally, the results of our questionnaire help to identify outcomes of specific interest to developing countries with relatively limited resources, particularly regaining functional independence after THA

Background. There are several surgical options available for patients with bilateral knee osteoarthritis including simultaneous bilateral TKA (BTKA) and staged approach. The appropriate and safe time interval between two stages is still controversial. The preset systematic review aims to determine the optimal time interval between two stages of BTKA. Methods. Pubmed database was searched from 1979 to 2013 for English-language studies that compared the outcomes of each surgical approach. Comparison was carried out on unilateral TKA and two-staged BTKA as well as on different time intervals in two-staged BTKA. Results. Eighteen studies that enrolled patients underwent TKA either unilaterally or bilaterally in one-stage and two-stage were enrolled in this systematic review. Statistically significant difference was observed in cardiac complications (OR= 1.15, 95% CI: 1.01–1.31; P=0.03) and wound complications (OR=1.18, 95% CI: 1.07–1.3; P<0.000) following two-staged BTKA compared with unilateral TKA. There observed significant differences in favor of bilateral two-stage TKA regarding other complications including mortality (OR=0.82, 95% CI: 0.7–0.95; P<0.00), PE (OR=0.71, 95% CI: 0.64–0.78; P<0.00), knee infection (OR=0.5, 95% CI: 0.45–0.55; P<0.00) and knee revision (OR=0.42, 95% CI: 0.37–0.48; P<0.00). Increasing time interval between two stages of TKA to more than 90 days, showed a lower risk for urinary (OR=0.12, 95% CI: 0.02–0.72; P=0.02) and respiratory (OR=0.05, 95% CI: 0–0.94; P=0.04) complications. Conclusion. The main finding of this study was that time interval of more than 90 days between two stages of BTKA may be associated with less complication rate, specially of urinary and respiratory system

Introduction. Superficial wound complications can occur in up to 10% of total knee arthroplasty (TKA) patients and have been associated with deep infection. The ideal material for TKA closure should fulfill the following requirements: 1) fast intraoperative application, 2) minimal wound complications and discomfort, and 3) can be removed by patients without a home care visit. We present our experience with a novel, non-invasive, removable skin closure system compared to conventional staple closure. Methods. We prospectively evaluated 105 consecutive patients who underwent unilateral or bilateral primary TKA and received skin closure consisting of the Zip 16 Surgical Skin Closure System (Zipline) for skin. All procedures were performed a by single surgeon (SBH) using a mini-midvastus approach. All patients were mobilized on the day of surgery and received 2 weeks of Rivaroxaban thromboprophylaxis. Patient demographics, medical comorbidities, in-hospital complications and wound healing and complications during the first 6-week post-operatively were recorded. Data was compared to a previous TKA cohort of 1,001 patients from the same surgeon who received staples for closure and warfarin for thromboprophylaxis. Results. Zip and staple patient groups had similar age, gender and BMI. There was a higher percentage of diabetic patients in the Zip closure group (12% vs. 10%). All 105 patients with Zip closure removed dressings themselves and had healed wounds with no noted drainage or blistering at six-weeks. Two patients had protruding subcutaneous vicryl stitches that were removed. In the staple group there were six knees (0.6%) that had wound drainage with 2 (0.2%) requiring reoperation for debridement and reclosure. Discussion. In our experience, the Zip 16 Surgical Skin Closure System is easy to apply, avoids the need for home care or office visit and had fewer wound complications compared to staples. Results have been positive despite the study cohort having a higher number of diabetic patients and using an anticoagulant which may be associated with higher risk of wound problems

Introduction. Systemic metal ion monitoring (Co;Cr) has proven to be a useful screening tool for implant performance to detect failure at an early stage in metal-on-metal hip arthroplasty. Several clinical studies have reported elevated metal ion levels after total knee arthroplasty (TKA), with fairly high levels associated with rotating hinge knees (RHK) and megaprostheses. 1. In a knee simulator study, Kretzer. 2. , demonstrated volumetric wear and corrosion of metallic surfaces. However, prospective in vivo data are scarce, resulting in a lack of knowledge of how levels evolve over time. The goal of this study was to measure serum Co and Cr levels in several types TKA patients prospectively, evaluate the evolution in time and investigate whether elevated levels could be used as an indicator for implant failure. Patients and Methods. The study was conducted at Ghent University hospital. 130 patients undergoing knee arthroplasty were included in the study, 35 patients were lost due to logistic problems. 95 patients with 124 knee prostheses had received either a TKA (primary or revision) (69 in 55 patients), a unicompartimental knee arthroplasty (7 UKA), a RHK (revision −7 in 6 patients) or a megaprosthesis (malignant bone tumours − 28 in 27 patients) (Fig 1). The TKA, UKA and RHK groups were followed prospectively, with serum Co and Cr ions measured preoperatively, at 3,6 and 12 months postoperatively. In patients with a megaprosthesis, metal ions were measured at follow-up (cross-sectional study design). Results (Fig 2 and 3). In primary knees, we did not observe an increase in serum metal ion levels at 3, 6 or 12 months. Two patients with a hip arthroplasty had elevated preTKA Co and Cr levels. There was no difference between unilateral and bilateral knee prostheses. In the revision group, elevated pre-revision levels were found in 2 failures for implant loosening. In both cases, ion levels decreased postoperatively. In revisions with a standard TKA, there was no significant increase in metal ions compared to primary knee arthroplasty. RHK were associated with a significant increase in Co levels even at short-term (3–12 months). The megaprosthesis group had the highest metal ion levels and showed a significant increase in Co and Cr with time in patients followed prospectively. With the current data, we could not demonstrate a correlation between metal ion levels, size of the implant or length of time in situ. Discussion. In primary knee arthroplasty with a standard TKA or UKA, metal ion levels were not elevated till one year postoperatively. This suggests a different mechanism of metal ion release in comparison to metal-on-metal hip arthroplasties. In two cases of revision for implant loosening, pre-revision levels were elevated, possibly associated with component wear, and decreased after revision. With RHK, slightly elevated ion levels were found prospectively. Megaprostheses had significantly elevated Co and Cr levels, due to corrosion of large metallic surfaces and/or wear of components which were not perfectly aligned during difficult reconstruction after tumour resection. Further research is needed to assess the clinical relevance of metal ion levels in knee arthroplasty. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction:. The clinical significance of serum metal ion levels alone in patients with stemmed MoM hip arthroplasty remains uncertain. This study aims to measure the metal ion levels in patients with unilateral and bilateral hip arthroplasty to see whether or not the patients with bilateral hips have higher metal ions. Patients and Methods. All the patients with bilateral MoM hip arthroplasty were identified from the research database. These patients were then matched with those in a similar age group who had a unilateral hip arthroplasty, but same University of California Los Angeles (UCLA) activity score. The UCLA activity scores along with other hip scores have been previously gathered for all the patients. Both sets of patients then had measurement of serum cobalt and chromium levels. The results were analyzed and compared. Results:. There were a total of 53 patients with bilateral hips and 53 matched patients with unilateral hips. The average serum Cobalt and Chromium levels were 34 nmol/L (range <10–76) and 23 nmol/L (range <10–104) respectively in the bilateral group; and 14 nmol/L (range <10–45) and 21 nmol/L (range <10–57) in the unilateral group. Given that the MHRA (UK) threshold levels deemed clinically significant are 120 nmol/L and 135 nmol/L for Cobalt and Chromium respectively; the results obtained here are not clinically significant. Conclusions:. One would normally expect, with mathematical reasoning, a patient with bilateral hip arthroplasty to have higher serum metal ion levels than a patient with unilateral arthroplasty. However, this study goes to show that it is not the case

There is ample data to confirm that Computer-assisted total knee replacement improves alignment of the limb when compared with the conventional technique. There is also published evidence that optimum alignment correlates with longevity of implants. CAS enables accurate component alignment of both femoral and tibial components. It enables accurate restoration of the posterior tibial slope which has important consequences for flexion range and stability of the component in flexion especially if mobile bearing implants are considered. CAS also aids in correctly orienting rotation of the femoral component; this has value in minimizing patellar maltracking. We will present our data showing accurate restoration of joint line and posterior femoral offset. As CAS ensures alignment, rotation, sizing and positioning of components, the surgeon is free to devote his efforts to ensuring soft-tissue balance and stability, since TKA is really a ‘soft-tissue’ operation. How CAS is of immense value in deformity correction and soft-tissue balancing will be illustrated with examples. It helps in better understanding and quantification of the effects of soft-tissue release on flexion-extension gaps and this is of great value not only for minimal deformities (to minimise releases) but also for severe deformities (to ensure complete correction by adequate release). CAS is invaluable in helping equalize flexion-extension gaps; how it can help balance the flexion gap to the extension gap by ‘virtual surgery’ will be depicted with examples. It is particularly useful in presence of hardware in the femur or tibia and for concomitant extra-articular deformity. We have also found a consistent improvement in recovery of functional milestones with CAS with similar results for both unilateral and bilateral TKAs. Furthermore, there is evidence to support that ensuring alignment has important benefits in improving functional and quality of life scores. In addition, those with alignment of mechanical axis within 3 degrees of normal have been shown to have a shorter stay in hospital by 2 days. Studies have shown reduced blood loss and incidence of emboli after CAS TKA. Using CAS routinely for all cases, the author is ‘time neutral’. While there is always room for improvement with evolving technologies and CAS is no exception, it already has enormous benefits in the performance and outcome of TKA, and is an important part of the surgical armamentarium for a successful knee arthroplasty

Background:. Blood loss, pain and wound healing contribute significantly to the perioperative morbidity after total knee arthroplasty. Prospective randomized controlled studies are lacking, to our knowledge. The purpose of this study was to determine whether platelet rich plasma (PRP) might prevent blood loss and postoperative pain and expedite wound healing following TKA. Methods:. Forty consecutive age, sex and BMI-matched patients who had unilateral or bilateral arthritis of the knee with similar deformity and preoperative range of motion were enrolled for this prospective randomized controlled double blinded clinical trial. Preoperative haemoglobin, range of motion, WOMAC and KSS scores were noted. Platelet-rich plasma was applied over the wound including the capsule, medial and lateral recesses in seventeen patients. Twentythree served as controls. Postoperative haemoglobin, blood loss, blood transfusion, VAS score, Wound score, KSS and WOMAC score were recorded and evaluated. Results:. Autologous platelet gel (APG) group had a smaller decrease in haemoglobin (Preop Hb–POD3 Hb) compared to control (1.97/3.56; p = 0.00). Postoperative blood loss was 173.2 ml vs 220.4 ml (p = 0.02). Blood transfusion was significantly less in the APG group (0.59 units/1.43 units; p = 0.001). APG group experienced less pain immediately, at 6 weeks and 12 weeks postoperatively (VAS 6.5/7.39, 2.67/3.84, 1.61/2.31; p = 0.00, 0.00, 0.00) and required fewer narcotics than control (15.24/22.65; p = 0.00). There was statistically significant difference in ROM at 5. th. day, 6 weeks and 3 months (79.44°/74.22°, 96.11°/87°, 97.6°/93.9° respectively; p = 0.00, 0.00, 0.01). There was no significant difference in the wound scores of two groups (30.96/34.23; p = 0.311). Significant difference was observed in KSS and WOMAC scores at 6 weeks (158.96/148.77, 17.3/23; p = 0.00, 0.00) and 12 weeks (166.96/161.42, 10.86/14.61; p = 0.00, 0.00). However no significant difference was found at 6 months. Conclusions:. We found significant reduction in blood loss, postoperative pain and need for narcotics after the use of autologous platelet gel in patients of total knee arthroplasty. Quicker and better functional outcome was observed in the APG group. However, at six months and later follow up, both groups had similar functional scores. Its role on wound healing was statistically insignificant. Level of Evidence: Therapeutic Level II

Introduction. Higher concentrations of metal ion levels after Metal-on-metal (MoM) THA are a cause for concern. Elevated cobalt (Co) and chromium (Cr) ion levels in the blood indicate metal wear, and may predict secondary soft-tissue damage (adverse reaction to metal debris; ARMD). Although, it is well known that concentrations of metal ion levels are elevated in the short term after MoM, the long-term consequences in ion concentration and risk factors for increased ion levels are not clarified. We sequentially investigated the postoperative Co and Cr ion levels after MoM THA and the relationship between the metal ion levels and several risk factors. Materials and Methods. We reviewed the data on one hundred and eighty six patients of two hundred ninety one MoM THA cases. The one hundred eighty six patients were measured at least three times after a MoM THA surgery over a five year (2005–2010) period in our institution. Serum cobalt and chromium levels were measured by inductor coupled plasma – mass spectrometry at several times in follow-up period, (measured at the preoperative period, the third month, the sixth month, the first year, the second year, and the fourth year after MoM THA). Furthermore, we investigated the correlation between the metal ion levels and various factors which might influence the release of metal ions, such as Body mass index (BMI), renal function, femoral head size, unilateral or bilateral THA, the cup position, and postoperative activity. The renal function was evaluated by measuring estimated glomerular filtration ratio (GFR) at preoperative examination. A postoperative activity was assessed with a pedometer measurement counting number of steps a day. A cup position was evaluated by lateral inclination measured by X-ray or computed tomography. Results. Average serum Co and Cr concentrations in preoperative period were 0.69 and 0.05 mg/ ml, respectively. Postoperative serum Co and Cr ion levels were significantly increased compared with preoperative value throughout the postoperative period. There was no significant correlation with regards to BMI, renal function, femoral head size tothe metal ion level measurement. In bilateral THA cases, Co and Cr ion concentrations were significantly increased compared with unilateral THA cases. In addition, in cases that its cup inclination was more than 50 degrees, Co and Cr ion concentration were significantly increased compared with cases less than 50 degrees in the first year after surgery. There was a trend for higher metal ion levels in the group of patients who walked more than 7000 steps a day, but this did not reach statistical significance. Conclusion. Metal ion concentrations of almost patients were increased after MoM THA surgery. Side effects related to elevation of serum Co or Cr concentration were currently not identified and overall clinical results were good. However, Longer follow-up would be necessary if the patients have overlapping risk factors, because those patients may experience elevation of the level in postoperative late stage

Introduction. Metal-on-metal hip resurfacings (MoMHRAs) have a characteristic wear pattern initially characterised by a run-in period, followed by a lower-wear steady-state. The use of metal ions as surrogate markers of in-vivo wear is now recommended as a screening tool for the in-vivo performance of MoMHRAs. The aims of this retrospective study were to measure ion levels in MoMHRAs at different stages during the steady-state in order to study the evolution of wear at minimum 10 years postoperatively and describe factors that affect it. Materials and methods. A retrospective study was conducted to investigate the minimum 10-year survivorship of a single-surgeon Birmingham Hip Resurfacing (BHR) series, and the evolution of metal ion levels. Implant survival, Harris Hip Scores (HHS), radiographs and serum metal ion levels were assessed. The evolution of metal ion levels was evaluated in 80 patients for whom at least two ion measurements were available at more than 12 months postoperatively, i.e. past the run-in phase. Ion level change (Delta Cr; Delta Co) was defined as Cr or Co level at last assessment minus Cr or Co level at initial assessment. Sub-analysis was performed by gender, diagnosis, age, femoral component size and cup inclination angle. Results. Overall Cr and Co levels were low (Cr: 1.3 μg/L; Co: 1.0 μg/L for unilateral and Cr: 3.2 μg/L; Co: 2.3 μg/L for bilateral resurfacings) and decreased significantly (p < 0.001) from the initial assessment at 4 to 8 years postoperatively (median 6 years) to the last assessment at 10 to 13 years (median 11 years) with a mean reduction of 1.24 μg/L for Cr (Median: −0.80; SD: 1.948; Range: −11.8 to +2.0 μg/L) (p < 0.001) and 0.88 μg/L for Co (Median: −0.75; SD: 1.645; Range: −7.5 to +5.3 μg/L) (p < 0.001). Three patients (4%) had an increase of Co ions >2.5 μg/L, associated with head sizes £50 mm and with clinical symptoms and high cup inclination angles. There was no significant difference in the change of ion levels between genders (Cr: p = 0.845; Co: p = 0.310) although Cr levels at initial and last assessments were higher in females (p = 0.008). Component size did not correlate with change in ion levels (Cr: p = 0.505; Co: p = 0.370). Patients with increased ion levels at follow-up had lower Harris Hip Scores (p = 0.038). Discussion. Low serum Cr and Co ion levels were found in patients with well-functioning unilateral and bilateral MoMHRA. In well-functioning MoMHRA ion levels continue to be low even after . 3. 10 years in situ. In this series, there were no symptomatic patients with low metal ion levels. Increasing metal ion levels >10 μg/l were invariably associated with poorly functioning MoMHRA. The analysis of consecutive ion levels demonstrated a statistically significant overall decrease of Cr and Co levels with time in well-functioning BHR. In 25% of patients ion levels were undetectable at . 3. 10 years postoperatively. Our data are in accordance with tribocorrosion studies indicating a lower-wear bedding-in phase after the initial running-in phase of higher wear. An increase in ion levels after the run-in phase is an indication of continued surface wear which may eventually lead to implant failure potentially associated with soft tissue and bone destruction

Aims

Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator.