Blood donation in England is voluntary and a limited resource. Blood transfusion is essential and beneficial in some postoperative hip replacements, however is not without inherent risks. Royal College of Physician audit in 2007 has shown wide variation in transfusion with an average rate of 25% (22% – 97%).

Patient blood management is an established approach to optimising need for post- operative transfusion. The Surgical Blood Conservation Service (SBCS) was set up in 2009 to enable a reduction in the demand for blood transfusion during and postoperatively in many orthopaedic procedures.

We aimed to achieve preoperative haemoglobin of 12g/dl (males) and 11g/dl (females). Low levels were treated with iron therapy. Surgery was deferred till satisfactory Hb levels were reached. During surgery cell salvage was routinely used. Transfusion was recommended at postoperative Hb < 8g/dl.

The transfusion rate was estimated at 47% in 2002. Following the introduction of SCBS, the transfusion rate reduced considerably to 7.9% in 2009 with a further reduction to 7.29% in 2011 and 3.16% in 2012. In 2013, 10 out of 442 hip replacements received transfusion (2.21%).

Our results demonstrate successful Patient blood management, minimising the need for post- operative transfusion.

There is strong evidence to support the use of bisphosphonates in the prevention of osteoporotic fractures. There has, however, been growing concern that prolonged use of bisphosphonates can lead to the development of atypical femoral fractures and can protract healing time.

We conducted a retrospective study looking at all femoral fractures between 2011–2013. Of 109 patients, 12 were diagnosed with atypical femoral fractures. The mean age of presentation was 69 (52–92). Five patients held no history of falls and presented with hip pain. The remaining seven sustained minor falls. Seven patients were on bisphosphonates on presentation. Bisphosphonates were discontinued in five cases and continued in two. Bisphosphonates commenced in one patient who subsequently developed second fracture. All fractures were managed with intramedullary nailing. Healing time was prolonged in all cases (mean healing time 7.3 months). Three patients needed further surgeries to achieve union.

Overall, we observed that patients with prolonged bisphosphonate intake were more susceptible to atypical fractures with a delayed recovery time.

Increasing awareness amongst medical professionals may aid timely diagnoses and subsequent referrals to orthopaedics. Recognition of these fractures may also permit early discontinuation of bisphosphonates, which may prevent future fractures and reduced healing times.

A prospective cohort study was undertaken to assess the success of Ossur Unloader knee brace as non-operative management of isolated medial compartment osteoarthritis.

We recruited 12 volunteers (14 knees, mean age 63) with isolated medial compartment arthritis. They were clinically assessed, demographic data and Oxford knee scores were collected before the use of the braces. At 6 months, patient satisfaction, change in symptoms and repeat Oxford scores were noted.

Improvement was noted in 5 patients (6 knees, 42%) whose mean BMI was 29. They gained confidence, knee stability and pain relief. Their mean Oxford score had improved from 28 to 41.

Bracing was unsuccessful in 7 patients (8 knees, 58%) whose mean BMI was 33. These patients were disappointed and had discontinued its regular use. Their mean Oxford score only improved from 21 to 23.

As yet no patient has undergone a knee Arthroplasty. Comparative weight bearing radiographs with and without brace reveal no change in the weight bearing alignment. 42% of the patients with a mean baseline Oxford score of above 25 and a mean BMI of below 30 responded favourably. The main causes of failure were lack of improvement in symptoms, discomfort, skin irritation and poor patient compliance.

Aim

We aim to show that our series of Avon Patellofemoral Joint Replacements (APFJR) with over 5 year follow up, have comparable functional, radiological and revision rate results to other published reports.

This study aims to show that our series of Avon Patellofemoral Joint Replacements (APFJR) with over 5 year follow up, have comparable functional, radiological and revision rate results to other published reports.

Retrospective analysis occurred for all consecutive cases of APFJR from October 1999 and January 2010; all operations were performed by the senior author (AL). Each patient had both clinical and radiological follow up. Patient demographics, pre and post op Oxford Knee scores and complications were all recorded. An independent post-operative radiological review took place to check for loosening and progression of disease. Revision to Total Knee Replacement was taken as the endpoint.

83 consecutive APFJR's were implanted in 56 patients for established isolated patellofemoral arthritis. The average age was 68.2(34-95) with 18 males and 38 females. The mean follow-up was 5.4 years (1.25 to 11). There were 5 revisions with the five-year survival rate being 95.2% (95% confidence interval 88.12% - 99.88%). The median Pre Op Oxford knee score was 17 of 48 points (interquartile range 11 to 21) showed significant improvement when compared to the median Post Op Oxford knee score of 35 (interquartile range 26 to 41). There was one superficial infection, no deep infections and one transient sciatic nerve palsy. These results compare very closely to those in the designing surgeon's series (Ackroyd et al JBJS Br 2007).

These results reveal satisfactory survivorship and functional outcome results in the medium term leading to increased confidence in the use of this patellofemoral arthroplasty.

Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) is associated with poorer outcomes. Our experience has not reflected this. We examined the Oxford Hip Scores (OHS), Harris Hip Scores (HHS) and outcomes of patients with varus hips against a normal cohort to ascertain any significant difference.

We identified 179 patients. Measurement of the femoral neck-shaft angle was undertaken from antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients with a NSA of less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with published anatomical studies.

The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74). Mean OHS and HHS were 16 and 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures, early failures or revisions. Normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76). The OHS and HSS were 18.8, 88.9 respectively. Complications included 5 trochanteric non-unions and 1 revision due to an acetabular fracture following a fall. Statistical analysis demonstrated no statistical difference between the cohorts OHS (p=0.583) or HHS (p=0.139).

Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no statistical difference in hip scores between the cohorts. We have not yet experienced any femoral neck fractures, which we believe is due to the use of the Ganz trochanteric flip and preservation of blood supply.

The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femeroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature.

We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fifteen MRA's demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap (carpet lesion) and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 96.7%, 73.3% and 92.9% respectively.

We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practise has changed to reflect this finding. For those patients with cysts on MRA, we are less likely to offer open debridement and favour arthroscopic intervention followed by arthroplasty when symptoms dictate. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment options accordingly.