The ideal operative treatment of displaced sub capital femoral fractures in the elderly is controversial. Recently, randomised controlled trials have suggested a better outcome with the use of total hip arthroplasty (THA) to treat displaced intra capsular fractures of the femur for elderly patients in good health. More recently the concept of dual mobility cups is being promoted to avoid dislocations in this cohort of patients. However, overall there is limited evidence to support the choice between different types of arthroplasty. Dislocation remains a main concern with THA, especially when a posterior approach is used.

We analysed the outcome of 115 primary THR (112 cements and 3 uncemented) THR using a posterior approach with soft tissue repair in active elderly patients presenting with displaced intra capsular femoral neck fractures. Size 28 mm head was used in 108 and a size 32 mm head in the rest. All surgery was performed by specialist hip surgeons.

Satisfactory results were noted in terms of pain control, return to pre-morbid activity and radiological evidence of bone implant osteo-integration. The 30-day mortality was nil. There were two dislocations and only one needed revision surgery due to recurrent dislocation.

In conclusion, with optimal patient selection, THA seems to provide a good functional outcome and pain relief in the management of displaced intracapsular femoral neck fractures. Excellent outcome can be achieved when done well using the standard cemented THR and with 28mm head. A good soft tissue repair and a specialist hip surgeon is preferable.

Introduction

An educated public are becoming increasingly aware of percutaneous needle fasciotomy (PNF) for the treatment of Dupuytren's contracture. We believe that it has an important place in the management of this condition and have set up a dedicated one-stop clinic to perform this procedure.

Introduction: The Optiplug^® bio-absorbable cement restrictor, marketed by Biomet inc., is manufactured from ‘PolyActive’ – a polymer of poly(ethylene glycol) and butylene terephthalate. Biodegradation is thought to be by a combination of hydrolysis and oxidation.

The potential benefit – eliminating the need for restrictor removal at future revision surgery – led to Optiplug becoming our cement restrictor of choice over the last 5 years.

Anecdotally we have seen marked osteolysis around the distal cement mantle in a number of follow up radiographs in these patients. To date we have not seen an associated peri-prosthetic fracture.

We undertook a retrospective, radiographic study to determine incidence, severity and progression of this osteolysis over the first 5 years of follow up.

Method: 100 patients for whom 5 year follow up had been undertaken were identified from the departmental database. Patients with loose prostheses and or infection were excluded as were those who had undergone revision surgery.

Radiographs from the immediate post operative period, twelve months and five years follow up visits were identified and reviewed.

Osteolysis was quantified by calculating the ratio of maximum medullary diameter to the overall cortical diameter of the bone. Comparison was made over time and, where radiographs allowed, to the immediately adjacent femur.

Results: 87% of radiographs showed greater than 10% thinning of the cortex at 1 year cf. immediate post op. 5 cases showed greater than 33% thinning. These changes do not appear to progress or regress significantly between 1 and 5 years.

Discussion: While marked osteolytic changes appear to be uncommon, some degree of cortical thinning was almost universal in this series. The zone immediately distal to the cement mantle is commonly involved in peri-prosthetic fractures. Any weakening in this area is undesirable.

Introduction: Studies have shown that the addition of adrenaline to the saline wash used in total knee replacements reduces blood losses. Our aim was to see if this held true for patients undergoing Total Hip Replacement (THR).

Materials and Methods: Between January 2007 and March 2008 we retrospectively looked at all total hip replacements performed by the senior author. The same standard peri-operative regimen was used throughout. All patients received Aspirin 150mg post operatively for six weeks as thrombo-embolic prophylaxis (unless specifically contra-indicated). All patients had a Bellovac A.B.T (Astra Tech) drain placed deep to the fascia lata at the end of each operation. Blood drained in the first 6 hours was re-infused. After six hours the drain continued to function as a ‘normal drain’. All drains were removed within 24 hours following surgery. Patients were assigned to two groups: one control group of 80 patients, in which a saline solution was used to wash the surgical field, and a second group of 59 patients, in which a saline solution containing a low dose of adrenaline (4mg of 1:1000 in a litre) was used to wash the surgical field.Haemoglobin was determined preoperatively and on the first postoperative day. The total blood loss was calculated. We also measured the decrease in haemoglobin for each patient. Statistical analysis was carried out using the SPSS statistical package.

Results: A total of 139 patients were reviewed. The patient characteristics in both groups were closely matched. No significant differences found in the drop in haemoglobin between both groups P = −0.426. The mean volume of blood lost intraoperatively was also similar. Study 299ml and Control 313ml respectively.

Discussion: Our study suggests that the use of adrenaline wash in patients undergoing THR is of minimal benefit in reducing blood losses. As there is no tourniquet used in THR perhaps this may be explained by the fact that as the circulation is not temporarily disrupted then the local effect of the adrenaline may be lost as it is being washed away at the time of application and local levels do not become sufficiently high to have the desired vaso-constrictor effect.

Introduction: Primary total hip replacement remains one of the commonest orthopaedic procedures performed. It is yet to be clearly demonstrated whether use of a postoperative drain is of benefit in these procedures.

Methods: We carried out a prospective randomised study comparing the use of autologous reinfusion drains, closed suction drains or no drain to determine their influence on allogenic blood transfusion requirements, length of hospital stay and infection rates. Stratification was carried out for confounding factors.

Results: 153 patients were recruited into the study and randomised to one of the three closely matched groups. There was no significant difference between the mean intra-operative blood loss or post-operative haemaglo-bin levels between the 3 groups. 42% of the suction drain group required post-operative transfusion as compared to 17% of the reinfusion drain group and 12% of the group with no drains. This difference was highly significant (P=0.02) Mean time for the wound to become dry was 3 days, 3.9 days and 4 days in the no drain, re-transfusion drain and suction drain groups respectively. This difference was statistically significant (P=0.03). There was no statistically significant difference in the mean length of inpatient stay.

Discussion: This study demonstrates a significantly higher transfusion rate with closed suction drains compared to reinfusion drains or no drains. With the drive to reduce hospital stay our study supports the considered use of no drain or a reinfusion drain.

The role of bone-graft extenders in impaction revision surgery is becoming increasingly important. Tricalcium phosphate and hydroxyapatite have been shown to be both biocompatible and osteoconductive, yet many surgeons remain reluctant to use them. The difficulty in handling bone-graft extenders can be partly alleviated by using porous particles and adding clotted blood.

In an in vitro model we measured the cohesive properties of various impaction graft mixes. Several factors were evaluated including the use of pure bone graft compared with mixes with extender, washing the bone and the addition of clotted blood.

Our findings showed that pure allograft bone particles had significantly higher cohesion than when mixed with extender (p < 0.001). Washing had no effect on cohesion. The addition of clotted blood significantly increased the cohesion of both pure bone (p < 0.019) and mixes with pure bone and with porous graft extender (p < 0.044).