Tranexamic Acid (TA) has been shown to reduce transfusion rates in Total Knee Replacement (TKR) without complication. In our unit it was added to our routine enhanced recovery protocol. No other changes were made to the protocol at this time and as such we sought to examine the effects of TA on wound complication and transfusion rate.

All patients undergoing primary TKR over a 12 month period were identified. Notes and online records were reviewed to collate demographics, length of stay, use of TA, thromboprophylaxis, blood transfusion, wound complications and haemoglobin levels. All patients received a Columbus navigated TKR with a tourniquet. Only patients who received 14 days of Dalteparin for thromboprophylaxis were included.

124 patients were included, 72 receiving TA and 52 not. Mean age was 70. Four patients required a blood transfusion all of whom did not receive TA (p = 0.029). Mean change in Hb was 22 without TA and 21 with (p = 0.859). Mean length of stay was 6.83 days without Tranexamic Acid and 5.15 with (p < 0.001). 15% of patients (n=11) of the TA group had a wound complication, with 40% of patients (n=21) in the non TA group (p = 0.003). There was one ultrasound confirmed DVT (non TA group). No patients were diagnosed with pulmonary embolus.

In our unit we have demonstrated a significantly lower transfusion rate, wound complication rate and length of stay, without any significant increase in thromboembolic disease with the use of TA in TKR.

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from aspirin to Rivaroxaban use routinely following lower-limb arthroplasty for venous thromboembolism (VTE) prophylaxis. The aim of this audit was to retrospectively review its efficacy and the morbidity associated with its use.

All patients undergoing primary and revision lower-limb arthroplasty between February 2011 and July 2011 were reviewed. All patients undergoing total knee replacement surgery and total hip replacement surgery received oral rivaroxaban 10 mg daily post-operatively for 14 days and 35 days respectively. Outcome measures recorded were; investigation for DVT/PE, rate of DVT/PE, wound complications (infection, dehiscence, leaking, bleeding), blood transfusion rate and readmission rate within 6 weeks of surgery.

Of the 162 patients identified, 19 were excluded due to insufficient information or because they did not receive rivaroxaban as VTE prophylaxis. 141 patients (mean age 71.7 years) were included. 69 primary and 5 revision total knee replacements were performed. 60 primary and 7 revision total hip replacements were performed. 9 patients (6.4%) underwent Doppler USS for a painful swollen leg with 1 (0.7%) DVT diagnosed. None were investigated for a pulmonary embolus. 25 (17.7%) patients developed wound complications: 10 superficial infections requiring oral antibiotics, 2 deep infections requiring theatre washout, 1 wound dehiscence, 5 continuously leaking wounds, 5 bleeding wounds/haematomas. 26 (18.4%) patients required post-operative blood transfusion (average 2.2 units). 12 (8.5%) patients were re-admitted within 6 weeks with post-op complications (6 wound complications, 5 painful/swollen limbs, 1 large per-vaginal bleed).

In keeping with previous literature, the rate of VTE following lower-limb arthroplasty using rivaroxaban as prophylaxis is low. However, the rate of morbidity was higher when compared with the use of aspirin in our centre between April and September 2010.

The routine use of a fixed distal femoral resection angle in total knee arthroplasty (TKA) assumes little or no variation in the angle between the anatomical and mechanical femoral axes (FMA angle) in different patients. The aims of this study were threefold, firstly to investigate the distribution of FMA angle in TKA patients, secondly to identify any correlation between the FMA angle and the pre-operative coronal mechanical femoro-tibial (MFT) angle and in addition to assess post-operative MFT angle with fixed or variable distal femoral resection angles.

277 primary TKAs were performed using either fixed or variable distal femoral resection angles (174 and 103 TKAs respectively), with intramedullary femoral and extramedullary tibial jigs. The variable distal femoral resection angles were equal to the FMA angle measured on pre-operative Hip-Knee-Ankle (HKA) digital radiographs for each patient. Outcomes were assessed by measuring the FMA angle and the pre- and post-operative MFT angles on HKA radiographs.

The FMA angle ranged from 2° to 9° (mean 5.9°). Both cohorts showed a correlation between FMA and pre-operative MFT angles (fixed: r = -0.499, variable: r = -0.346) with valgus knees having lower FMA angles. Post-operative coronal alignment within ±5° increased from 86% in the fixed angle group to 96% when using a variable angle, p = 0.025. For post-operative limb alignment within ±3°, accuracy improved from 67% (fixed) to 85% (variable), p = 0.002.

These results show that the use of a fixed distal femoral resection angle is a source of error regarding post-operative coronal limb malalignment. The correlation between the FMA angle and pre-operative varus-valgus alignment supports the rational of recommending the adjustment of the resection angle according to the pre-operative deformity (3°-5° for valgus, 6°-8° for varus) in cases where HKA radiographs are not available for pre-operative planning.

The recognition of the correct pattern and severity of deformity in knee osteoarthritis has important implications in its surgical management. Our unit routinely uses standing long leg films and computer navigation. However, these modalities are not widely available and most surgeons rely on clinical assessment and short films. Our experience is that clinical assessment can give the opposite impression of the true deformity pattern particularly among obese patients and there is evidence that short knee films are not reliable. Our study aims to compare clinical, radiographic and computer measurements of knee deformity, assess the influence of Body Mass Index and asses the relationship between coronal and flexion deformity.

We measured 52 consecutive knees prior to arthroplasty using clinical, long leg radiographs and computer navigation methods. Systematic clinical measurement was done with patient standing. Standing radiographs stored in a Picture Archiving System were measured by two independent observers. The senior surgeon performed computer measurement while applying axial load to the foot to simulate weight bearing.

Using long leg films as baseline, clinical and X-ray measurement had a mean error of 0.8° (−12 to +12). Seven clinically valgus knees turned out varus on X-ray. Mean BMI for this group was the same as the rest. Using navigation as baseline, clinical and navigation coronal measurements had a mean error of 0.3° (+9 to −10.5). Four clinically valgus knees turned out varus with navigation. Mean BMI for this group was the same as the rest. Flexion deformity was similar between clinical and computer measurement. Three clinically normal knees showed significant varus in both X-ray and navigation. Compared directly, radiographic and navigation coronal deformity showed significant difference in the degree of deformity but not in the pattern of deformity. There was no correlation between BMI and both the error in clinical assessment of coronal deformity and navigation coronal alignment. If flexion deformity was > 5°, higher BMI indicates higher flexion deformity. There was a weak correlation between navigation coronal and flexion deformity.

Although error in clinical measurement did not reach statistical significance, based on our result, clinical assessment can give an incorrect pattern of deformity in up to 13% and hence should not be the sole basis of assessing deformity. Contrary to expectation, BMI did not influence error of clinical assessment or severity of coronal deformity. It however appeared to influence larger flexion deformities. The discrepancy between radiographic and navigation measurements reflects the absence of true weight bearing with navigation even though we tried to simulate this by applying axial load to the foot.

Many studies have already been published to prove the improved accuracy in achieving the ideal post-operative long leg alignment when using computer navigation in total knee arthroplasty (TKA). Surgeons who use traditional instrumentation with a fixed distal femoral resection angle (most commonly 6°) assume little or no variation in the angle between the anatomical and mechanical axis of the femur (FMA angle) in different patients.

The aims of this study were to investigate the distribution of the FMA angle in pathological knees of patients about to undergo TKA and to analyse if there was any correlation between the FMA angle and the pre-operative lower limb alignment in the coronal plane (varus or valgus).

The study consisted of 158 consecutive patients undergoing 174 primary TKA between January and October 2007. All patients had pre-operative digital Hip-Knee-Ankle radiographs. The FMA angle and the mechanical femorotibial angle (MFT angle) were measured in all cases. Intra- and inter-observer variation was measured by second observer readings and repeated measurements.

The mean age of the study cohort was 69.9 years (SD 8.7 years). There were 75 male and 99 female knees. The repeatability for measurement of the FMA angle was good (intra-observer Intra Correlation Coefficient (ICC) = 0.91, inter-observer ICC = 0.85) and for the measurement of MFT angle was very good (intra-observer ICC = 0.99, inter-observer ICC = 0.99). There were 135 knees with a varus or neutral alignment and 39 knees with valgus alignment. The median alignment was 6.5° varus ranging from 23° varus to 16° valgus. The FMA angle was between 2° and 9°, with a median of 6°. The FMA angle was 6° in 35.4% of cases, 5° in 22.9% and 7° in 18.3%. There was a statistical significant correlation between the FMA angle and the pre-operative lower limb alignment (Pearson correlation coefficient = −0.5, p < 0.001), with valgus knees having on average a lower FMA angle. The group of females and males had statistically different FMA angles (Mann-Whitney, p < 0.001) with females having on average a lower FMA angle. Cluster analysis based on the original clinical definitions of severe varus, varus and valgus gave three groups of FMA angle for MFT angle < 8° varus, MFT angle of 8° varus to 1° valgus and MFT angle > 1° valgus. There was a statistically significant difference in median FMA angle between these three groups (Kruskal-Wallis, p < 0.001).

This study indicates that one of the main reasons why optimal post-operative coronal alignment cannot be achieved with a fixed distal femoral resection angle is the fact that the FMA angle has a wide, natural distribution. It is possible that better results may be achieved with traditional instrumentation by individual measurement of FMA angle for each patient pre-operatively and adjusting the distal femoral resection to account for this. However, with computer navigation the distal femoral cut is adjusted for each patient.

Background: Selective ultrasound screening of neonatal hips with risk factors has been undertaken in Lanarkshire from 2001. Referral reasons included family history, breech, clicky hip and instability. Patients are examined by an orthopaedic surgeon with a special interest and scanned by static Graf technique. Our experience with selective screening and its effect on late DDH is presented.

Methods: All ultrasound screening data was collected prospectively and entered into a database. Late presenters were identified at the tertiary centre by case note and X ray review. Population data was obtained from the Scottish registry.

Results: Between 2001–2005, there were 30,824 live-births. 405 babies (910 hips) were identified as being at risk. 5(1.2%) were identified as Graf III/IV. Three responded to splinting, 1 required closed reduction and 1 open reduction. 11 who had initially normal scans were noted to have abnormal acetabular index (> 30) at 6 months. 2 required open reduction, 1 closed reduction and the rest eventually normalised with follow up. True late presentation was identified (> 3 months) in 11 children. Mean age at diagnosis was 14.7m (4–29 mts). 7(64%) did not have any identifiable risk factors. 4 had risk factors, but had escaped screening. 8 underwent open and 3 closed reduction. 7 derotation osteotomies and 1 pelvic osteotomy were additionally performed.

Discussion: The identifiable incidence of DDH in Lanarkshire is 0.87/1000. The incidence of true late presenting DDH in the same population was 0.35/1000. If all hips with risk factors had been successfully screened it would reduce to 0.22/1000. Selective screenings can minimise the incidence of late presenting DDH if rigorously implemented. Majority of late presenters do not have risk factors and are likely to escape detection with a selective screening programme. This suggests a different natural history in late presenting cases.

Aim: To assess the efficacy of selective ultrasound screening for DDH, with and without an orthopaedic examination.

Method: From 2002 our secondary DDH screening program was changed. Newborns with risk factors were referred directly for hip ultrasound. The orthopaedic surgeon was not involved if ultrasound was normal. An audit for 1997–2001 found an average annual incidence of 0.57(29 cases). The audit was extended to 2005 by identifying late DDH cases presenting from 2002 onwards, using the same criteria.

Results: Ninety-six cases were identified. After excluding children born outside Glasgow 36 cases were left for audit. The yearly incidence per 1000 live-births is shown below. The average incidence for 2002–2005 was 0.95. No significant difference between the two periods was found (p= 0.3).

Average age at diagnosis was 14.9 months. Two had risk factors but had not been screened. Thirty-one hips were dislocated, two were subluxed and one had borderline dysplasia that resolved. Twenty needed open reduction. Sixteen of 22 patients over 1 year at treatment required open reduction compared to 5 of 13 treated age 1 year or less (p = 0.046). Ten had femoral osteotomy, five a pelvic osteotomy, and five both femoral and pelvic osteotomy. There was one postoperative infection.

Conclusion: Direct ultrasound screening of infants with risk factors without concomitant assessment by an orthopaedic surgeon has not significantly altered the incidence of late DDH.