Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. A review of the English-language literature identified 23 citations eligible for inclusion. A total of 2063 bilateral simultaneous THR patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.365) and dislocation (p=0.877) when comparing staged or unilateral with bilateral simultaneous THR procedures. A systematic analysis of heterogenous data demonstrated that mean length of hospital stay was shorter after bilateral simultaneous THR. Blood loss was reduced after bilateral simultaneous THR in all studies except for one, and surgical time was not different between groups. This procedure was also found to be economically and functionally efficacious when performed by experienced surgeons in specialist centres.

Periprosthetic femoral fractures around total knee arthroplasty present a challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate (PMMA) cement in five patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and behaves like a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their pre-injury functional status within four months. This procedure does not disrupt the soft tissue envelope facilitating periosteal callus formation, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction in octogenarians unfit for lengthy procedures, nailed cementoplasty is proposed as a salvage procedure.

In selected patients in-cement revision of the total hip arthroplasty components is an attractive option. Recommended roughening of the primary mantle surface remains controversial. Aim of the study was to investigate the influence of the cement surface roughening on the strength of bilaminar cement interface.

Flat, laboratory model of bilaminar cement interface was used. Prior to its creation, modeled primary mantle surface was machined to the roughness of either smooth surface observed after removal of a highly polished stem (Ra=200nm) or that following roughening (Ra=5μm). Two viscosities of interfering fluids (water and bone marrow) were also used. 6 variants (smooth or rough, both stained with water, bone marrow or with no fluid) with 7 repeats were exposed to single shear to failure.

No significant difference in resistance to shear was observed between the groups with dry smooth (16.82MPa) and rough surfaces (16.96MPa), and those stained with large volume of low viscosity fluid. In the presence of water, roughening did not significantly influence the interface (smooth – 17.04MPa and rough – 16.25MPa respectively).

In the smooth variant with large volume of viscous fluid, ultimate stress value dropped to 5.53MPa, and 9.87MPa in the roughened group with the same amount of viscous fluid (p< 0.05).

Extra roughening may offer some benefit when performing in-cement revision in the presence of large volume of viscous fluid only though in-cement revision would not be then recommended. In the presence of low viscosity fluids (blood, irrigation fluid) benefit of roughening is dubious.

Controversy still remains as to whether patella resurfacing in total knee arthroplasty (TKA) should be conducted as a matter of routine. Some authors recommend routine resurfacing of the patella and advocate this due to the reduction in post-operative anterior knee pain and the reduction in requirement for revision surgery.

A database search was conducted to identify prospective randomized controlled studies only. Eighteen prospective randomized trials were identified and found eligible for inclusion. A cumulative sample of 8006 knees were involved, 3418 undergoing resurfacing and 4588 undergoing no resurfacing. Primary outcome data extracted was incidence of secondary operations, incidence of anterior knee pain and functional outcome scores including subgroup analysis of the type of prosthesis used in each study. Der Simonian Laird metanalysis was conducted if studies were found to be homogenous where statistical significance was defined as an overall alpha error of < 0.05.

No statistically significant differences were found to exist between patients undergoing patella resurfacing as a primary total knee replacement and those who preserved the native patella. No differences could be found between specific prosthetic design when subgroup analysis was conducted.

The study does not offer evidence to suggest any advantage of resurfacing versus non-resurfacing. Furthermore, no significant discrepancy existed when comparing different types of total knee prosthesis. This may be due that all the knees analysed are designed to be patella friendly and allow conformity of articulation of both a native and patella button equally

During hip revision removal of old cement mantle is a major problem. In cases of satisfactory bond between cement mantle and the underlying bone, cementing the revision stem into the old mantle is regarded as a highly attractive option. The aim was the analysis of the shearing strength of the interface between two layers of poly-methylmethacrylate cement in the presence of fluid.

A laboratory, two-dimensional model of the interface was used. Effect of different viscosity fluids and volumes on its strength was checked. 6 variants (control monoblock, dry surface, surface stained with small or large volume of water or highly viscous fluid) containing 7 repeats were exposed to a single shearing stress to failure.

Large volume of viscous fluid prevented bonding completely in two cases and significantly weakened the other samples showing mean failure stress of 5.53 MPa. This was significantly lower compared with control monoblock (19.8MPa), dry surface variant (16.9MPa) and the stain with small amount high viscosity fluid (16.01MPa). Interestingly, presence of a large volume of low viscosity fluid did not significantly reduce resistance to shear stress (17.05MPa).

In all but large volume of viscous fluid variants, the failure occurred away from the interface between two cement layers. Large amount of viscous fluid weakened significantly this interface. If such a viscous fluid could be eliminated by copious water irrigation it is likely that strength of the cement-cement bond will be maintained. Our observations suggest that cement-in-cement technique seems to be biomechanically acceptable

Background: The recognised risk of post-operative venous thromboembolism (VTE), presenting as deep vein thrombosis (DVT) and/or pulmonary embolism (PE), after elective total hip and knee arthroplasty (THA and TKA) has always made the selection of suitable thromboprophylaxis treatment a clinical priority for orthopaedic surgeons. Over recent years there has been the emergence of new oral direct Factor Xa (FXa) inhibiting anticoagulants, which may replace the widely used low-molecular-weight heparins (LMWHs).

Methods: A systematic review of published English-language literature (completed in July 2009) and surgical type meta-analyses were conducted to compare the efficacy (risk of any DVT, PE and all-cause mortality) and safety (risk of major bleeding requiring clinical intervention) of oral direct FXa inhibiting anticoagulants with LMWHs in THA and TKA.

Results: Five eligible THA randomised-controlled trials (RCTs) with total of 9286 patients and three eligible TKA RCTs with 6917 patients were identified. The Der-Simonian-Laird random effects model was employed for each meta-analysis and heterogeneity between trials was explored statistically using the Mantel-Haenszel χ² test. The efficacy meta-analysis of THA RCTs revealed an odds ratio (OR) 0.46 (95% confidence interval (c.i.) 0.23, 0.92), which was significantly (P = 0.03) in favour of the oral FXa inhibitors but there was sizable heterogeneity amongst trials (P = 0.0002). Although the safety meta-analysis of THA RCTs showed an increase incidence of major bleeding with the use of oral FXa inhibitors, OR 1.71 (95% c.i. 0.67, 4.39), this risk was not statistically significant (P = 0.26) with little heterogeneity between trials (P = 0.44). The efficacy meta-analysis of TKA RCTs demonstrated an efficacy OR 0.56 (95% c.i. 0.42, 0.73), in favour of the oral FXa inhibitors (P = 0.0001) with no significant heterogeneity (P = 0.21). The safety meta-analysis of TKA RCTs showed an increased occurrence of major bleeding with oral FXa inhibitors, OR 1.79 (95% c.i. 0.83, 3.87), but this was not statistically significant (P = 0.14) and heterogeneity between trials was low (P = 0.54).

Conclusions: This review demonstrated an overall better efficacy for oral FXa inhibitors compared with LMWHs in thromboprophylaxis for both THA and TKA. Although it also revealed that oral FXa inhibitors were statistically as safe as LMWHs, there was clinically higher incidence of major bleeding with their use in both THA and TKA. These safety results coupled with the fact that currently no specific antidote exists, highlights the urgent need for further research and large RCTs to prove the clinical safety of all new oral direct FXa inhibiting anticoagulants.

Background: During cemented hip arthroplasty revision removal of all the old cement mantle is a time staking process with multiple disadvantages. In some selected patients cementing revision stem into the old mantle is regarded as a highly attractive option. Contradictory evidence exists whether bond between two cement layers is strong enough, especially in the presence of interfering fluids.

Aim: analysis of the shearing strength of the interface between two layers of polymethylmethacrylate cement in the presence of fluid.

Methods: Cylindrical blocks of polymethylmethacrylate cement represented primary cement mantle. Its flat surface was machined to reproduce smooth old cement mantle surface comparable with that after removal of a highly polished stem (Ra=200nm). A second block was cast against the first and their junction represented the investigated interface. The influence of fluid was examined by injecting liquid onto the ‘primary’ surface prior to casting. Water or 2% water solution of carboxy-methyllcellulose (representing bone marrow viscosity of 400mPas) were used in two volumes: 0.02ml/cm2 (small) or 0.4ml/cm2 (large - surface submerged).

6 variants (control monoblock, dry surface, surface stained with small or large volume of water or highly viscous fluid) containing 7 repeats were exposed to a single shearing stress to failure at the speed of 1mm/min (Autograph AGS, Shimadzu, Japan).

Results were analyzed using 1-way ANOVA with post-hoc analysis (equal N HSD) and power calculations.

Results: Large volume of viscous fluid prevented bonding completely in two cases and significantly weakened the other samples showing mean failure stress of 5.53 MPa (95%CI:1.33–9.73 MPa). This was significantly lower compared with control monoblock (19.8–95% CI: 17.8–21.9 MPa), dry surface variant (16.9–95% CI: 15.9–18.0 MPa) and that stained with small amount of high viscosity fluid (16.01–95% CI: 15.12–17.0 MPa). Interestingly, presence of a large volume of low viscosity fluid (water) did not significantly reduce resistance to shear stress (17.05 – 95% CI:15.67–18.43 MPa).

Similar relations were observed when strain at failure and toughness were analyzed.

Conclusions: In all but large volume of viscous fluid variants, the failure occurred away from the interface between two cement layers. Large amount of viscous fluid weakened significantly this interface. If such a viscous fluid can be eliminated by copious water irrigation it is likely that strength of the cement-cement bond will be maintained. In the presence of low viscosity fluids (water, blood) careful use of gun technique is likely to allow for their escape as the cement is advanced within the femoral or the old mantle canal leading to a satisfactory bond. Our observations suggest that cement-in-cement technique seems to be biomechanically acceptable.

Introduction: Ever since the coding has been introduced in the NHS there has been lot of debate whether the trust is being paid accurately. There is no data available which compares the coding done by the surgeon and the one done by the coding department.

Material and Methods: A prospective study was done on 305 patients in an elective orthopedic hospital over a period of one month. All operations were coded separately by the operating surgeon and the coding department. The procedures included all upper and lower limb procedures other than elective hand, spine and paediatric procedures. The results were compared by an independent assessor in line with the national guidelines and the information originally available to clinical coders.

Results: The results showed a marked difference in reimbursement cost of complex procedures, revisions and co-morbidities as coded by the surgeon who took into consideration additional top ups which were available and these were often missed by the coding department. There was no difference in the primary hip and knee arthroplasty.

Conclusion: There is an increased need for correct coding as this can result in potential income consequences by applied tariffs. With the introduction of acute phase tariffs and marked difference in reimbursement to the trust if correct codes are not applied, there is an increased need for awareness for the coding and the top-ups available for complex procedures.

Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. Twenty three citations were eligible for inclusion. A total of 2063 BSTHA patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.356) and dislocation (p=0.877) when comparing SgTHA or UTHA versus BSTHA procedures. Systematic analysis of heterogenous data demonstrated that mean length of stay was shorter in BSTHA as compared to SgTHA and UTHA procedure, blood loss was lower in BSTHA in all studies except one, whilst the surgical time was not different between groups. BSTHA was also found to be economically and functionally efficacious.

There is believed to be a correlation between congenital idiopathic scoliosis and congenital heart disease (CHD). Clinical and cardiological data was recorded for 3538 adolescents suffering from CHD. Data collected included the type of scoliosis; the direction of the curve; the Cobb angle; the number of curves and the presence or not of previous corrective cardiac surgery. Over 30% of the study group were found to suffer from scoliosis and a positive correlation with specific syndromes was also identified. The mean age of the patients was 34.0 +/− 14.0 years. The maximum Cobb angle was 107 degrees while the median was 7.6 degreees. Scoliosis was present in 37/188 (19.7%) was Eisenmenger syndrome (with R-L shunt) and 60/158= 38% with complex cardiac anatomy. There were also 20/103= 19.4% patients with univentricular (Fontan) circulation. Scoliosis was not necessarily related to previous corrective cardiac surgery, contrary to the current assumption in the literature. The hypothesis of common genetic pathway defects expressed both in cardiovascular and musculoskeletal organogenesis was raised and the TGF-beta pathway involvement is speculated.