Introduction: Total hip-joint arthroplasty is associated with a high rate of peri-operative blood transfusion, which has associated risk. Previous studies have identified individual factors than can predict those patients most at risk of post-operative allogenic blood transfusion. We undertook this study to attempt to identify further factors that may predict post-operative blood transfusion.

Methods: Data was collected pre-operatively for patient demographics including type of surgery, sex, age, BMI, ASA, pre-operative haemoglobin & pre-operative packed cell volume for all total hip arthroplasties performed by a single surgeon over twelve months (Total number 233; 166 primaries, 33 resurfacing & 20 revision arthroplasties: 14 excluded for insufficient data). Post-operative data collection included post-operative haemoglobin levels and allogenic transfusion requirements.

Results: Of 166 patients who underwent primary hip arthroplasty, 25 (15.1%) received allogenic blood transfusions, an average volume of 2.1 units per patient transfused. Analysis revealed significant predictive factors of gender (females > males, p=0.0019), advancing age (p=0.0045), lower height (p< 0.0000), lower pre-operative weight (p=0.0010), lower pre-operative haemoglobin (p< 0.0000), and lower pre-operative packed cell volume (p< 0.0000). Patients who underwent revision surgery were also more likely to have undergone transfusion compared to both primary (6.1% transfused, p=0.025) and resurfacing arthroplasty (35% transfused, p=0.009). BMI and ASA were found to not be significant risk factors. Pre-operative packed cell volume (PCV) showed the strongest correlation with post-operative blood transfusion. Cases with a PCV below the average of 39% had a rate of transfusion of 28%, 6.4 times greater than for those patients above the average at 4.4% (p< 0.0000).

Discussion: Pre-operative measurements of height, weight, haemoglobin and packed cell volume, together with factors including sex & type of surgery can identify those patients who are at greater risk of post-operative transfusion allowing selective transfusion prevention strategies.

Considerable controversy remains in the literature as to whether hemiarthroplasty or total shoulder arthroplasty (TSA) is the better treatment option for patients with shoulder arthritis. Several cohort studies have compared the outcomes of stemmed hemiarthroplasty with those of stemmed TSA and had inconsistent conclusions as to which procedure is best. However, these studies suggest that stemmed TSA provided better functional outcome. 340 CSRA cases were performed between 1987–2003, 218 Hemiarthroplasty – Humeral Surface Arthroplasty (HSA) and 122 TSA. There was very little difference in the functional outcome and pain in patients with and without a glenoid implant early, as well as, later after surgery. Mean post-operative Constant score for TSA was 85.0% (59.8 points) and for HSA patients 86.8% (62.3 points) with no statistically significant differences (t-test, p=0.4821). A highly significant difference between the overall proportions of revised cases was observed, with (21/122) 17.2% and (6/218) 2.8% of TSA and HSA cases revised, respectively (p< 0.0001). Further, HSA prostheses survive significantly longer than TSA prostheses. The difference between the survival curves was highly significant, both in the earlier post-operative period (Wilcoxon’s test, p=0.0053) as well as the later on (Log-rank test, p=0.0028). Long-term survival of total joint replacement is related to polyethylene wear debris, and therefore its use should be avoided if possible. The difference between our series and those with stemmed prostheses may be due to the fact that with surface replacement the normal anatomy for each patient can be mimicked better than with the stemmed prostheses and there is substantially less place for error as in stem positioning, head sizing or wrong version that may lead to glenoid erosion and less favourable result. Our current practice is and we suggest performing Copeland humeral surface replacement without insertion of glenoid prosthesis.

Introduction Pridie and Steadman independently noticed the development of a smooth layer of fibrocartilage when treating exposed subchondral bone in the knee using their techniques of drilling or microfracture respectively. Since 1997, patients presenting to our unit for a Copeland cementless Surface Replacement Arthroplasty (CSRA) with a congruent glenohumeral joint have routinely undergone biological resurfacing of the glenoid using a technique similar to that described by Pridie and Steadman. We present this technique of glenoid resurfacing, the histological and surgical outcomes in a consecutive group of patients.

Methods/Results Between 1987 and 2002, 218 CSRA were performed without replacing the glenoid. From 1997, 133 CSRA have been performed with multiple drilling of the glenoid face with a guide wire through the subchondral bone in to the underlying soft cancellous bone to stimulate bleeding. This causes formation of a fibrocartilaginous layer – biological resurfacing. 9 (6.8%) of the patients with biological resurfacing have subsequently undergone a shoulder arthroscopy for postoperative impingement pain. This allowed us to evaluate the glenoid surface – macroscopically a layer of cartilage was noted in all patients, intraoperative biopsies have confirmed this layer to be fibrocartilage microscopically. In the biological resurfacing group, the mean postoperative Constant score (CS) is 86.9 (age/sex adjusted), with a mean improvement in CS of 71.0. 3 (2.3%) patients have required revision.

Conclusion Our results confirm that glenoid drilling at the time of CSRA leads to the formation of a fibro-cartilaginous layer over the glenoid, with significant improvements in Constant scores and functional outcomes. These results are comparable to other published results for total shoulder replacement with polyethylene resurfacing of the glenoid and better than patients that have undergone stemmed shoulder hemiarthroplasty.

We describe the results of Copeland surface replacement shoulder arthroplasty using the mark III prosthesis in patients over 80 years of age. End-stage arthritis of the shoulder is a source of significant pain and debilitating functional loss in the elderly. An arthroplasty offers good relief of pain and may allow the patient to maintain independence. The risk-benefit ratio of shoulder replacement may be felt to be too high in an elderly age group, but there is no published evidence to support this theory. We have assessed whether the procedure was as reliable and safe as previously seen in a younger cohort of patients. Between 1993 and 2003, 213 Copeland surface replacement arthroplasty procedures were performed in our unit, of which 29 (13.6%) were undertaken in patients over the age of 80. This group of patients was followed up for a mean of 4.5 years (2.1 to 9.3). Their mean age was 84.3 years (81 to 93), the mean operating time was 40 minutes (30 to 45) and the mean in-patient stay was five days (2 to 21). There were no peri-operative deaths or significant complications. The mean Constant score adjusted for age and gender, improved from 15.1% to 77%. Copeland surface replacement shoulder arthroplasty may be performed with minimal morbidity and rapid rehabilitation in the elderly.

Copeland Surface replacement arthroplasty provides a good outcome in cases of arthritis. However, the limitation of use of this prosthesis is severe bone loss of the humeral head.

We describe the use of Copeland Surface Replacement Shoulder Arthroplasty in cases of severe humeral head destruction extending more than 50% of the humeral head. The bone deficiency was reconstructed with the autograft from the reaming and reshaping of the humeral head and a synthetic bone graft substitute (Tricalcium phosphate granules (Biosorb)) mixed with the patient’s blood.

We report preliminary results in 8 cases. 3 males and 4 females (One patient bilateral). The average age was 48 years ( 22–76 years). 5 cases had Posttraumatic avascular necrosis of humeral head, two patients had locked posterior fracture dislocation with loss of more than 50% of the humeral head and one patient with severe juvenile rheumatoid arthritis.

In this series the remaining bone of humeral head was less than 50% ranging between 30–50% (average 38%).

The patients were followed clinically and radiographically. The average follow–up was 10.6 months (range: 5 to 15 months).

All patients had substantial improvement in there shoulder function and pain. All the patients were very satisfied. Average pre-op constant score was 9.3 points (range: 9–14). At the latest follow-up the average constant score was 59 (range: 36–74). Age and sex adjusted constant score was 68.6 (range: 37– 87).

Radiographically we observed good incorporation of the Bone graft substitute with no signs of loosening or any lucencies under the prosthesis.

These are early and encouraging results in this group of young patients with severe destruction of the humeral head. It seems like it may provide a good bone preserving solution in these cases and extend the frontiers for the surface replacement of the shoulder.