The practice of removing a well-fixed cementless femoral component is associated with high morbidity. Ceramic bearing couples are low wearing and their use minimises the risk of subsequent further revision due to the production of wear debris. A total of 165 revision hip replacements were performed, in which a polyethylene-lined acetabular component was revised to a new acetabular component with a ceramic liner, while retaining the well-fixed femoral component. A titanium sleeve was placed over the used femoral trunnion, to which a ceramic head was added. There were 100 alumina and 65 Delta bearing couples inserted.

The mean Harris hip score improved significantly from 71.3 (9.0 to 100.0) pre-operatively to 91.0 (41.0 to 100.0) at a mean follow up of 4.8 years (2.1 to 12.5) (p < 0.001). No patients reported squeaking of the hip.

There were two fractures of the ceramic head, both in alumina bearings. No liners were seen to fracture. No fractures were observed in components made of Delta ceramic. At 8.3 years post-operatively the survival with any cause of failure as the endpoint was 96.6% (95% confidence interval (CI) 85.7 to 99.3) for the acetabular component and 94.0% (95% CI 82.1 to 98.4) for the femoral component.

The technique of revising the acetabular component in the presence of a well-fixed femoral component with a ceramic head placed on a titanium sleeve over the used trunnion is a useful adjunct in revision hip practice. The use of Delta ceramic is recommended.

Cite this article: Bone Joint J 2013;95-B:333–8.

Introduction: Blood loss is a major concern following total knee arthroplasty (TKA) frequently resulting in blood transfusions postoperatively. Various strategies exist to reduce blood loss and allogenic transfusion requirements. This study investigates the effect of immediate postoperative flexion on blood loss and transfusion requirements following TKA.

Methods: 180 consented patients undergoing primary TKA by a single surgeon were enrolled into a prospective randomised controlled study. 90 patients were randomised to have the operated knee nursed in extension postoperatively, and 90 patients to have the knee nursed in flexion for six hours postoperatively. Both groups followed a strict transfusion protocol. Data collected included calculated pre- and postoperative haemoglobin and haematocrit which was used to calculate total blood loss. Units transfused and postoperative complication rates were also recorded.

Results: There was no significant difference in demographics or factors predisposing to bleeding between the groups. The mean total blood loss was 1841mls for those in the extension group compared with 1587mls in the flexion group (p=0.02). The mean number of units transfused in the extension group was 0.78 units/patient compared with 0.36 units/patient in the flexion group (p=0.004). There was no significant difference in pain scores between the groups (p= 0.62).

Conclusion: This study shows that the use of immediate postoperative flexion significantly reduces calculated total blood loss and transfusion rates following TKA.

Patients and Methods: One hundred and fifty patients with pre-operative haemoglobin levels of 13.0g/dl or less were enrolled into a randomised controlled trial comparing the blood saving effect of intravenous tranexamic acid and topical fibrin spray on blood loss following primary total knee arthroplasty.

Those randomly assigned to the Tranexamic Acid group received 500mg intravenously five minutes prior to tourniquet deflation and a repeat dose three hours later. Those assigned to the Topical Fibrin Spray group received 10mls of the combined product intra-operatively. Those in the control group received no pharmacological intervention.

Results: There was a significant saving in total calculated blood loss for those in the topical fibrin spray group (p=0.016) and the tranexamic acid group (0.041) compared with the control group with losses of 1190mls, 1225mls and 1415mls respectively. The increased reduction in blood loss in the topical fibrin spray group was not significantly different to that in the tranexamic acid group (p=0.72).

We performed a randomised, controlled trial involving 150 patients with a pre-operative level of haemoglobin of 13.0 g/dl or less, to compare the effect of either topical fibrin spray or intravenous tranexamic acid on blood loss after total knee replacement.

A total of 50 patients in the topical fibrin spray group had 10 ml of the reconstituted product applied intra-operatively to the operation site. The 50 patients in the tranexamic acid group received 500 mg of tranexamic acid intravenously five minutes before deflation of the tourniquet and a repeat dose three hours later, and a control group of 50 patients received no pharmacological intervention.

There was a significant reduction in the total calculated blood loss for those in the topical fibrin spray group (p = 0.016) and tranexamic acid group (p = 0.041) compared with the control group, with mean losses of 1190 ml (708 to 2067), 1225 ml (580 to 2027), and 1415 ml (801 to 2319), respectively. The reduction in blood loss in the topical fibrin spray group was not significantly different from that achieved in the tranexamic acid group (p = 0.72).

Purpose: The objective of this study was to assess whether a correlation existed between blood loss and soft tissue release carried out during total knee replacement in the valgus knee.

Method: We identified 208 patients with a valgus deformity undergoing primary total knee arthroplasty . These were performed over a 33 month period by a single surgeon. An LCS mobile bearing prosthesis was used in all patients. The valgus deformity range was from 1–38 degrees with a mean of 11.75 degrees. Haemoglobin (Hb) drop was calculated as a measure of blood loss. This was calculated using:

Hb drop = Pre-op Hb – (Day 3 Hb + No. of units of blood received)

(We assumed that one unit of blood equates to one gram increase in circulating haemoglobin).

Results: Osteoarthritis was the major diagnosis (90.3%) followed by rheumatoid disease (5.8%). Forty-four patients (21%) required no soft tissue release, this group having an average deformity of 6 degrees and an average Hb drop of 4.35g/dl. One hundred and forty-six (69%) patients required a posterolateral capsular release, average deformity of 14 degrees with an average Hb drop of 4.63g/dl. Seventeen (8%) patients had a posterolateral and an additional Iliotibial band release, average magnitude of deformity 18 degrees and average Hb drop of 4.97g/dl. One patient had a lateral collateral ligament release, magnitude of deformity 30 degrees and haemoglobin drop of 6.4g/dl.

Conclusion: Soft tissue release in total knee arthroplasties in the valgus knee increases the amount of postoperative bleeding and average length of stay of the patient.

Purpose: We describe our management of the valgus knee including release of tight lateral structures using a medial approach.

Method: Controversy surrounds which approach to use when undertaking a total knee replacement (TKR) in a fixed valgus knee. Poor patellar tracking is associated with this deformity and often rectified by a lateral retinacular release. Those favoring the lateral approach feel, although more demanding, it gives direct access to the tight lateral structures and avoids excessive devas-cularization to the patella, which may be associated with a lateral release and a medial arthrotomy.

Two hundred and eight consented patients (24.2%) were identified from 860 primary knee arthroplasties carried out over a 33-month period by a single surgeon. An LCS mobile bearing prosthesis was used in all cases. The mean valgus deformity measured 12.1 degrees (range 1–38). Fifty four percent of patients had a deformity of greater than 10 degrees. The patella was not resurfaced in any patient.

Results: Forty-four patients (21%) required no soft tissue release. The mean deformity was 6 degrees (range 2–13). Of the remaining 164 patients, 142 (87%) had a posterolateral capsule release, 17 (10%) posterolateral capsule and iliotibial band release, 4 (2.4%) posterolateral and direct posterior capsule release and 1 (0.6%) a lateral collateral ligament slide for fixed valgus deformity. The mean valgus deformity increased with each additional release required.

Of note 61 (29.3%) patients required a lateral patellar release for patellar maltracking. No patellar complications were noted. Mean patellar tilt was 1.1 degrees (sd=0.6 degrees) and mean patellar congruency 98% (sd=0.7%).

Conclusion: Using a medial approach in the valgus knee is technically less demanding than a lateral approach, can be used in any primary knee irrespective of the type of deformity and can restore patellar alignment without compromising viability at least in cases where the patella is not resurfaced.