The primary aim was to assess whether patients waiting 6-months or more for a total hip (THA) or knee (KA) arthroplasty had a deterioration in their health-related quality of life (HRQoL). Secondary aims were to assess change in level of frailty and the number living in a state worse than death (WTD).

Eight-six patients waiting for a primary TKA or KA for more than 6-months were selected at random from waiting lists in three centres. Patient demographics, waiting time, EuroQol 5-dimension (EQ-5D) and visual analogue scores (EQ-VAS), Rockwood clinical frailty score (CFS) and SF-36 subjective change in HRQoL were recorded at the time of and for a timepoint 6-months prior to assessment. The study was powered to the EQ-5D (primary measure of HRQoL).

There were 40 male and 46 female patients with a mean age of 68 (33 to 91) years; 65 patients were awaiting a THA and 21 a TKA. The mean waiting time was 372 (226 to 749) days. The EQ-5D index deteriorated by 0.222 (95%CI 0.164 to 0.280, p<0.001). The EQ-VAS also deteriorated by 10.8 (95%CI 7.5 to 14.0, p<0.001). CFS progressed from a median of 3 to 4 (p<0.001). The number of patients WTD increased from seven to 22 (p<0.001). Thirty-one(36%) patients felt their HRQoL was much worse and 28 (33%) felt it was somewhat worse.

Patients waiting more than 6-months had a clinically significant deterioration in their HRQoL and demonstrated increasing level of frailty with more than a quarter living in a health state WTD.

We present a review of 97 consecutive BioPro^® metallic hemiarthroplasties performed in 80 patients for end-stage hallux rigidus, with a minimum of five years follow-up.

The mean age of the cohort was 55 (22 to 74) years. No patient was lost to follow-up. There were 15 revisions performed, one for infection, two for osteolysis, and 12 for pain. The all cause survival rate at five years was 85.6% (95% confidence interval (CI) 83.5 to 87.9). Younger age was a significant predictor of revision (odds ratio 1.09, 95% CI 1.02 to 1.17, p=0.014) on excluding infection and adjusting for confounding variables (Cox regression). Significant improvements were demonstrated at 5 years in the Manchester Oxford foot questionnaire (13.9, 95% CI 10.5 to 17.2) and in the physical component of the short form 12 score (6.5, 95% CI 4.1 to 8.9). The overall satisfaction rate was 72%. The cost per quality-adjusted-life-year at 5 years, accounting for a 3% per year revision rate, was £3,714.

The BioPro offers good short to mid-term functional outcome and is a cost effective intervention. The relative high revision rate is associated with younger age and the use of this implant may be limited to older patients.

Introduction:

The purpose of this study was to elucidate the specific radiographic effects that the Cotton osteotomy confers when used in combination with other reconstructive procedures in the management of the flexible flat foot deformity.

Whilst clinical pathways have reduced the length of inpatient stay (LOS) and costs associated with total hip replacement (THR), it would be useful to be able to predict which factors affect the LOS following THR. In this way units could improve patient flow, and thus increase efficiency, by optimising case loads and staffing levels in all related departments. We hypothesised that there were pre-operative factors that will predict the length of inpatient stay following a unilateral primary THR.

Prospective data from 2302 patients who underwent primary unilateral THR for osteoarthritis during a nine-year period from January 01 1998 were included. The relationship between each prospectively recorded factor and LOS was analyzed separately using t-tests or Pearson correlation. Multiple linear regression was used to analyze the effect of each significant factor adjusted for others.

Length of stay varied from 3 to 58 days, with a mean of 8.1 and a median of 7.0. The pre-operative factors that were not significantly associated with the LOS were BMI, Scottish Index of Multiple Deprivation, disabling knee, back or contra-lateral hip pain. A number of pre-operative factors were found to be highly significant predictors of LOS when subjected to univariate analysis, but not significant after multivariate analysis. These were smoking, heart disease, diabetes, pre-operative aspirin, pre-operative haemoglobin and overall Short Form (SF-36) score. Pre-operative factors that were significantly associated with LOS after adjusting for the effect of others were age, sex, pre-operative NSAIDs, consultant surgeon, combined function/activity dimension to Harris hip score, general health perception (GHP) dimension of SF-36, the day of the week and the year of surgery.

Younger age, male sex, higher combined Harris hip function and activity score, higher GHP dimension of SF-36 score and NSAID use are all significantly associated with reduced length of inpatient stay following primary THR for osteoarthritis.

Introduction: Increasingly, clinical pathways and fast-track protocols are reducing hospital in-patient stay following elective joint replacement surgery. In order to improve efficiency in our unit, we undertook a prospective observational study to identify pre–and peri-operative factors associated with increased length of stay.

Methods: From our prospective primary hip arthroplasty database we analysed data from 2678 consecutive patients over a 9-year period from 1998–2007. Patients were excluded who had bilateral hip replacement, died within 30 post-operative days, or had surgery for a diagnosis other than primary osteoarthritis. This left 2302 patients who were analysed using multiple logistic regression analysis

Results: Length of stay varied from 3 to 58 days, with a mean of 8.1 days, and median 7 days. After multivariate analysis, factors that were found to be significantly associated with shorter length of stay were younger age (p< 0.001), male sex (p< 0.001), more recent year of admission (p=0.008), regular non-steroidal anti-inflammatory medication (p< 0.001), lower Harris Hip Score (p< 0.001), and higher General Health Perception dimension score on SF-36 questionnaire (p< 0.001). In addition, the absence of blood transfusion during admission (p< 0.001) and absence of post-operative urinary catheter (p< 0.001) were also associated with shorter length of stay. The following factors, in particular, were not found to be significantly associated with increased length of stay: obesity, diabetes, smoking, medical comorbidity, other disabling joint condition, use of wound drain post-operatively.

Conclusions: We have identified a number of pre-operative factors that predict likely length of stay in a large cohort of patients undergoing primary hip replacement. This data could be used in the future for resource allocation and to improve efficiency in this significant area of healthcare.

Background: Several factors can alter a cements viscosity and hence it’s handling characteristics. An in vitro study was performed to ascertain whether anecdotal observations of differences in handling between batches of the same cement brand existed.

Methods: 3 batches of Simplex P Tobramycin (SPT), Refobacin Bone Cement (RBC), SmartSet GHV (SSG) and Palacos R+G (PRG) were tested. 6 replicates of each batch were vacuum mixed and their viscosity in relation to time was measured in laboratory conditions (50 ±5% humidity and 23 ±1°C) using a rheometer. 6 replicates of each batch had their handling characteristics examined after they were hand mixed in theatre conditions.

Results: Inter and intra-batch variability was seen in the viscosity of all brands of cements tested. Inter-batch calculations were influenced by high intra-batch viscosity variability. The viscosity of RBC cement was very similar to SSG, but significantly different to PRG (p = 0.01 at 5N and p = 0.009 at 40 N).

Interpretation: Our results suggest that in clinical practice extrinsic factors such as preparation conditions and methods probably play a more important role than the cements intrinsic variability. However, variability in handling and viscosity will exist in all brands of cement prepared in theatre conditions and the surgeon needs to be aware why they may act differently.

Introduction: An intra-medullary cement restrictor is an integral part of modern cementing technique in total hip arthroplasty. Failure of the restrictor to contain cement, flawed surgical technique or dislocation of the restrictor during pressurisation can all result in a deficient cement mantle. A radiographic analysis of hip replacements using a biodegradable restrictor was undertaken to determine the incidence of restrictor failure, the influence of femoral canal morphology on restrictor failure and to describe the cement mantle quality in successful and failed distal cement restriction.

Methods: x-rays from 299 consecutive hip replacements using the amberflex restrictor were analysed. The cortical index, canal-calcar ratio and femoral type, according to Dorr, were recorded. 3 modes of restrictor failure were identified:

Cement leakage –cement was seen to have escaped past the cement restrictor

Results: 84 cases of restrictor failure were observed – 44 dislocations, 24 leakages and 16 penetrations. The mode of failure was not correlated with femoral type, cortical index or canal-calcar ratio. A strong association was found between restrictor failure and grades c and d cement mantles using the chi squared test. A correlation between cortical index, canal-calcar ratio and femoral type was not observed.

Discussion: The ability of a cement restrictor to occlude the femoral canal and resist pressurisation is very important if a good quality cement mantle is to be achieved. Technical error was likely to be an important factor in many of the observed cases of restrictor failure, especially penetrative failure. Surgical technique is more important than femoral morphology in determining the successful use of this restrictor.

We performed 41 core decompressions in 32 patients for stage I or stage II osteonecrosis of the femoral head. The intra-osseous pressure at the intertrochanteric level was raised in 28 (68%) and there was histological confirmation of necrosis in 36 hips (88%). After a follow-up of 10 to 84 months (mean 31) nine of the 12 stage I hips (75%) showed significant clinical or radiological deterioration; no evidence of necrosis had been found in the core specimens of the other three hips. Of the 29 hips in stage II, 25 (86%) showed significant radiological deterioration, and only five (17%) had improved clinically. We believe that once necrosis has occurred, core decompression will not significantly influence the subsequent course of the disease.

A white child with a long history of illness from the age of six was thought at first to have Hodgkin's disease. There followed an acute illness with lesions involving glands, lungs, bone and skin. Mycobacterium avium-intracellulare group (Battey) was isolated from various lesions at the age of thirteen. After six years of continuous treatment the patient, now eighteen, is living a normal life.