Revision of a cemented hemiarthroplasty of the hip may be a hazardous procedure with high rates of intra-operative complications. Removing well-fixed cement is time consuming and risks damaging already weak bone or perforating the femoral shaft. The cement-in-cement method avoids removal of intact cement and has shown good results when used for revision total hip arthroplasty (THA). The use of this technique for the revision of a hemiarthroplasty to THA has not been previously reported.

A total of 28 consecutive hemiarthroplasties (in 28 patients) were revised to a THA using an Exeter stem and the cement-in-cement technique. There were four men and 24 women; their mean age was 80 years (35 to 93). Clinical and radiographic data, as well as operative notes, were collected prospectively and no patient was lost to follow-up.

Four patients died within two years of surgery. The mean follow up of the remainder was 70 months (25 to 124). Intra-operatively there was one proximal perforation, one crack of the femoral calcar and one acetabular fracture. No femoral components have required subsequent revision for aseptic loosening or are radiologically loose.

Four patients with late complications (14%) have since undergone surgery (two for a peri-prosthetic fracture, and one each for deep infection and recurrent dislocation) resulting in an overall major rate of complication of 35.7%.

The cement-in-cement technique provides reliable femoral fixation in this elderly population and may reduce operating time and rates of complication.

Cite this article: Bone Joint J 2015;97-B:1623–7.

Resuscitation decisions are part of routine practice and raise difficult, sensitive issues. We present experience of Do-Not-Attempt-Resuscitation (DNAR) decision-making in our unit.

Patients and staff (medical, nursing) completed a questionnaire to ascertain current practice, knowledge, and patient feeling regarding DNAR decisions.

Consultants and Registrars make DNAR decisions, junior-doctors and nurses feel they have insufficient knowledge. Senior-doctors were most familiar with BMA and Trust guidelines. The majority of all staff felt every patient should be asked. Consultants thought DNAR decision-making was least necessary.

Half of patients felt doctors had not explained the necessity of DNAR decisions and half felt conversations could have been handled better. Half said they had not been asked their opinion. Two-thirds would like more visual information.

UK-wide figures show 15% survival to discharge of in-hospital arrest; a-third of medical staff knew this. Registrars were most optimistic and consultants and ward doctors most pessimistic. All patients believed survival rate was 50%.

Important DNAR decisions are based on poor knowledge and communication. We developed an education programme for staff and information-video for patients and relatives to improve service. Video for DNAR discussions has not been previously used; it will provide a framework on which to approach this sensitive issue.

Introduction

The management of young patients with painful medial compartment osteoarthritis remains controversial. Opening wedge medial high-tibial osteotomy using a locking plate has shown good results in selected patients. This cohort of patients has high physical demands and previous studies have warned against operating on patients with increased body mass index (BMI).