The European Working Time Directive is a directive from the Council of Europe to protect the health and safety of workers in the European Union. The working time directive currently ensures a 56 working hour week and by August 2009 a 48 hour maximum working week. To accommodate such a reduction in working hours, the on call rotas for institutions have had to change. Has this had an affect on trauma exposure for current specialist registrars?

Materials and Methods: Data collection was from electronic logbooks of orthopaedic specialist registrars and locum appointment trainees on the Southwest Thames rotation. From the elogbooks indexed trauma procedures were audited, this included: dynamic hip screw, hemiarthroplasty, open reduction and internal fixation ankle, intramedullary nail femur, intramedullary nail tibia, and intramedullary nail humerus. The data was divided into year groups and then the data was subdivided into on call rotas. Obtained from the data collection was the number of indexed linked operations carried out per 6 months per year group.

Results: The data collection was over an 18 month period October 2006 – April 2008. The total number of trainee logbooks who had the complete data from the logbook available was 90. The number of trainees for each year = n, the total number of operations =x and mean number of operations for each year of training =μ. The results for year groups are as follows:Year 1 n=18, x=4897, μ= 272:Year 2 n=12, x=2853, μ= 238: Year 3 n=22, x=4106, μ= 187:Year 4 n=19, x=3176, μ= 167:Year 5 n=4, x=658, μ=165:Year 6 n=15, x=3249, μ=217.Data for on call rotas were subdivided into the following groups: 1in13, 1in9, 1in8 and 1in7. The number of trainees for each on type of on call rota =n, the total number of operations = x, the mean number of operations for each on call rota group = μ.The results were as follows:1in13 on call: n=12, x=2215, μ=185; 1in9 on call: n=11, x=3195, μ=290

1in8 on call: n=20, x=3754, μ=188; 1in7 on call: n=47, x=9775, μ=208

The results for the number of indexed linked operations carried out per 6 months per year group are as follows:YEAR 1 257.73:YEAR 2 228.24:YEAR 3 173.49: YEAR 4 173.23:YEAR 5 164.50: YEAR 6 208.49

Conclusion: The results show that year groups 1, 2 and 6 have carried out the highest number of procedures. The data also shows that trainees on the lowest frequency of on call rota call have the lowest number of indexed operations. The results for the number of indexed linked operations carried out per 6 months per year group shows that as the year groups progress the number of procedures carried out continues to decrease from year 1 to 5 and then increases again at year 6. The structure of orthopaedic training is being overhauled. The need for effective training has intensified. This audit aims to demonstrate some of the effects of the changes made in higher speciality training in orthopaedics.

We prospectively evaluated the long-term outcome of 158 consecutive patients who underwent revision total hip replacement using uncemented computer-assisted design-computer-assisted manufacture femoral components. There were 97 men and 61 women. Their mean age was 63.1 years (34.6 to 85.9). The mean follow-up was 10.8 years (10 to 12).

The mean Oxford, Harris and Western Ontario and McMaster hip scores improved from 41.1, 44.2 and 52.4 pre-operatively to 18.2, 89.3 and 12.3, respectively (p < 0.0001, for each). Six patients required further surgery. The overall survival of the femoral component was 97% (95% confidence interval 94.5 to 99.7). These results are comparable to those of previously published reports for revision total hip replacement using either cemented or uncemented components.

We present the 10- to 17-year results of 112 computer-assisted design computer-assisted manufacture femoral components. The total hip replacements were performed between 1992 and 1998 in 111 patients, comprising 53 men and 58 women. Their mean age was 46.2 years (24.6 to 62.2) with a mean follow-up of 13 years (10 to 17). The mean Harris Hip Score improved from 42.4 (7 to 99) to 90.3 (38 to 100), the mean Oxford Hip Score from 43.1 (12 to 59) to 18.2 (12 to 51) and the mean Western Ontario MacMasters University Osteoarthritis Index score from 57.0 (7 to 96) to 11.9 (0 to 85). There was one revision due to failure of the acetabular component but no failures of the femoral component. There were no revisions for aseptic loosening. The worst-case survival in this cohort of custom femoral components at 13.2 years follow-up was 98.2% (95% confidence interval 95 to 99). Overall survival of this series of total hip replacements was 97.3% (95% confidence interval 95 to 99).

These results are comparable with the best medium- to long-term results for femoral components used in primary total hip replacement with any means of fixation.

Introduction: We present the results of a prospective study of the blood transfusion requirements in patients undergoing a Bernese periacetabular osteotomy (PAO) with the use of an intra-operative cell-saver and without pre-donated blood. These data were compared with an earlier audit of patients who underwent this procedure without use of a cell saver.

Material and Methods: A cohort of 50 patients (56 hips) underwent a PAO for hip dysplasia between December 2006 and November 2008 performed by the senior author. The average age was 29 years (17–51) and there were 38 females and 12 males. The average weight was 69.96 kg (46–110) and the mean duration of operation was 136 minutes (100–240). A cell saver (Fresenius-Hemocare, Germany) was used intra-operatively for this cohort. Pre-operative Hb, post-operative Hb taken the day after surgery and any units transfused were documented. A post-operative transfusion policy was adopted where a haemoglobin (Hb) concentration of < 7.5 g/dl was an indication for transfusion or where a patient was sufficiently symptomatic

Results: The mean pre-operative Hb was 13.60 g/dl (10.8–15.9) and the mean post-operative Hb was 9.91 g/dl (6.4–11.8). Overall 4 patients received post-operative allogenic blood transfusion; 3 patients receiving one unit and one patient receiving 2 units. No patients received intra-operative allogenic blood.

Conclusion: Compared to our previous audit, the use of the cell saver resulted in an improvement in the mean post-operative Hb, (9.2 g/dl compared to 8.0 g/dl). The transfusion rate was also reduced (7.27% compared to 10.8%)..

Background: There is no consensus on the most appropriate prosthesis for treating osteoarthritis (OA) of the hip in young, highly active patients. Modern hip resurfacing is bone conserving, more stable and theoretically easier to revise than total hip arthroplasty. Early results of metal on metal resurfacing have been promising. We have compared two well matched cohorts of patients with regard to function, pain relief and patient satisfaction.

Methods: This prospective study included 2 cohorts of well matched patients treated with hip resurfacing (137 patients, 141 hips) and custom uncemented (CADCAM) stems (134 patients, 141 hips). All procedures were performed by a single surgeon. Outcome measures included Oxford, WOMAC and Harris hip scores. Statistical analysis was performed using the unpaired student’s t- test.

Results: One hundred and thirty four and 137 patients were included in the hip replacement and resurfacing groups respectively. The mean age of these patients was 54.6 years. The mean duration of follow up for the resurfacing group was 19.2 months compared to 13.4 months for the replacement group.

Pre operative oxford, Harris and WOMAC scores in the THA group were 41.1, 46.4 and 50.9 respectively while the post operative scores were 14.8, 95.8 and 5.0. In the HR group, pre- operative scores were 37.0, 54.1 and 45.9 respectively compared to 15.0, 96.8 and 6.1 post operatively. The degree of improvement was similar in both groups.

Conclusion: There was no significant difference in short term outcome between the groups of patients treated with hip resurfacing and total hip arthroplasty in the short term.

Introduction: One of the most important factors affecting the outcome of revision THR of the femoral stem is the variability of femoral endosteal geometry after removal of the in-situ stem. A custom made implant would greatly reduce the inventory of the ‘Off the shelf” (OTS) components. This study presents the medium to long-term results of a cohort of patients with this revision prosthesis.

Methods: During the period November 1991 to November 1998, 158 patients were implanted with a computer-assisted design and computer-assisted manufactured (CAD-CAM) revision prostheses (Stanmore Implants Worldwide, Biomedical Engineering Unit, RNOH) by the senior author (SMA). There were 97 males and 61 females. The average age was 63.1 years (34.6 – 85.9). The indications for revision surgery were aseptic loosening (135 cases, 85.4 %), peri-prosthetic fractures (6 cases, 3.8 %), infection (12 cases, 7.6%) and liner wear (3 cases, 1.9%).

Results: At 10 years all patients reported relief of pre-operative pain and the average hip flexion was 95o (90 o –110o). Oxford, Harris and WOMAC hip scores in the pre-operative and post-operative period were 41.1, 44.2 and 52.4 respectively and 18.2, 89.3 and 12.3 respectively (p< 0.0001, p< 0.0001, p< 0.0001).

There were 6 complications (3.8%) in this series; a periprosthetic fracture of the femoral diaphysis (1), posterior dislocation (2), failure secondary to aseptic loosening of the implant (1) and deep vein thromboses (2)

Discussion: These ten year results are encouraging and suggest that there is a role for the use of custom implants in revision THR, particularly where the anatomical variance of the proximal femur makes the use of OTS implants unsuitable.

Introduction: While the explant device has made revision of uncemented acetabular components technically easier, the unique design of the Birmingham Hip Resurfacing(BHR) acetabular component precludes the use of the standard explant extractor. The dual radius geometry of this socket causes impingement and damage to the curved blade of this device.

A novel adaptor was designed to correct for the differential radii and enable removal of the well fixed BHR socket with the explant. We present the results of our initial experience with this device.

Method: A prospective study was performed to evaluate the effectiveness of this device for revising the well fixed BHR socket. All cases were performed by a single surgeon via a posterior approach.

The explant cup extractor was used with its standard centering head and curved blades. The size of the explanted cup, last reamer size and size of the implanted component were recorded

Results: Three males and 7 females were included. Their average age was 58.1 years (48–65). Average time to revision of the BHR sockets was 24.2 months (7–40). Average explanted cup size was 51mm (46–58) and final reamer size 53.8mm (51–59). Average final socket size was54.8 (50–62). Overall there was a mean 2.8.mm size difference between the explanted cup and the final reamer.

Discussion: The thickness of the blade of the explant was 2mm therefore only 0.8 mm of bone was lost on average. The device enables a simple reproducible removal of the well fixed BHR sockets with preservation of acetabular bone stock.