Introduction: The advent of digital radiological technology affords orthopaedic surgeons with the opportunity to better assess prosthetic alignment. The purpose of this study was to determine whether a post-operative digitalised 3-foot standing film better helps the surgeon than the standard weight-bearing short analogue antero-posterior film.

Materials and Methods: A single surgeon’s series of 68 consecutive patients were included in this prospective study. The axial alignment, mechanical, anatomical axes and distance of the post-operative mechanical axis from the centre of the knee, of 71 total knee replacements were determined using computer software on digital 3 feet standing films (Agfa ADC-2S system). These results were compared to similar measures determined using a goniometer and standard short standing analogue antero-posterior films. Both sets of results were compared to the intra-operative distal femoral valgus cut used by the surgeon.

Results: Sixty-eight patients, 71 knees, average 68.1 (range 42–85) years were included in this study. The average length of time from surgery to complete radiological evaluation was 18.9 (range 2–40 months). A mean difference of 1.20 degrees was found between the valgus angles measured on digital long and standard short radiographs. This difference was statistically significant p< 0.05. Comparing both sets of films revealed a Pearson correlation co-efficient of 0.65. Comparing the valgus angle determined on the digital 3 foot standing film to the intra-operative valgus cut revealed a Pearson correlation co-efficient of 0.388, this figure compares to a correlation co-efficient of 0.240 when the standard short films are used. The postoperative mechanical axis was found to be on average 7.34 (range 0.0 – 30.6) mm from the centre of the knee and the implants were positioned on average 89.8° to the mechanical axis on digitalised films, both these measures were indeterminable on the short standard films.

Conclusion: Three-foot digital standing antero-posterior films are more accurate and better correlate with the surgeon’s pre-operative aims than standard short antero-posterior standing radiographs. Only digital films allow for accurate determination of the post-operative mechanical axis. Despite not using expensive computer aided navigation systems intra-operatively, implant positioning was very satisfactory. Short films are adequate for routine assessment of total knee replacements postoperatively but digital 3-foot standing films afford better accuracy and are preferable for research purposes.

It has been well documented that leg length discrepancy can be associated with back, knee and hip problems. Less is known about the effect on the foot. The effect of a simulated leg length discrepancy on foot loading patterns and gait cycle times in normal individuals was investigated.

Thirty feet of normal volunteers were evaluated using a ‘Musgrave Footprint Computerised Pedobarograph System’. Leg length discrepancy was simulated using flexible polyurethane soles of 1 to 5cm thickness, secured to the sole of a sandal worn on the opposite foot. Recordings of foot pressures and load were made barefoot (control) and then recordings were taken with simulated leg length discrepancies of 1 to 5cm. As leg length discrepancy increased, the total loading on the foot increased from 35. 31 to 37. 99 kg/cm²/sec, the forefoot loading increased from 15. 58 to 19 kg/cm²/sec, whereas hindfoot loading remained the same. Further analysis of forefoot loading revealed that all subjects except for female middle loaders demonstrated increased hallux loading as the leg length discrepancy increased (p< 0. 0001). Analysis of gait cycle time with increasing leg length discrepancy showed that the contact phase of gait decreased from a mean of 22% to 13% (p< 0. 0001), the midstance phase remained the same, whereas the propulsion phase increased from 44% to 50% (p< 0. 003).

This study demonstrates for the first time that leg length discrepancy has manifest changes in the foot. When prescribing orthotics to address leg length discrepancy, orthopaedic surgeons should consider attempts to relieve the increased pressure on the 2nd and 3d metatarsal heads, or incorporate a metatarsal bar to decrease the time of metatarsal loading.

In Ireland and the United Kingdom, there were 22 deaths as a direct result of blood transfusion during the period October 1996 to September 1998. Added to this there were 366 complications directly related to blood transfusion. With the introduction of a Haemovigilance Nurse and changing surgical personnel we were anxious to review transfusion rates in our Regional Orthopaedic Centre for the period January 1999 to July 2000.

All patients undergoing primary or revision arthroplasty in our Regional Orthopaedic Unit during the study period were reviewed. 459 primary or revision arthroplasties were performed in the study period.

Prior to the introduction of a Haemovigilance Nurse, transfusion rates for primary arthroplasties averaged 1. 41 units/patient, with 74% of patients being transfused. After the introduction, transfusion rates averaged 0. 51 units/patient, with 31% of patients being transfused.

Prior to the introduction of a Haemovigilance Nurse revision arthroplasties averaged 2. 5 units/patient, with 100% of patients being transfused. After the introduction transfusion rates averaged 1. 2 units/patient, with 62% of patients being transfused. There was a statistically significant difference between transfusion rates prior to and post the introduction of a Haemovigilance Nurse (p< 0. 005).

In the current climate post the Finlay Tribunal in Ire-land and the resultant increased public awareness, transfusing a patient without justifiable cause is no longer acceptable. Patients in this Unit are now transfused according to clinical needs and accurate measurement of intra-operative and post-operative blood loss, compared to their calculated maximum allowed blood loss (MABL). Our new transfusion protocol is working well without compromising patient care.