Hip and knee arthroplasties are very common operations in the UK with over 70000 hip and over 80000 knee arthroplasties taking place in England and Wales in 2011. Fortunately mortality following these operations is rare. However it remains important to understand the incidence and causes of death, in order to manage risk where possible and to inform the consent process.

This study aimed to evaluate the incidence and causes of death within 30 days after undergoing hip or knee arthroplasty in our unit and to highlight possible risk factors.

We looked at 30 day mortality in all patients undergoing hip or knee arthroplasty in our institution between 2005 and 2011. Data on post-operative deaths was derived from the Scottish Arthroplasty Project and correlated with procedural and demographic data from our hospital Patient Administration System (PAS). The notes of all patients who had died within a period of 30 days post-operatively were reviewed to collect data on co-morbid conditions, pre-operative investigations, post-operative thromboprophylaxis and cause of death. All primary and revision knee and hip arthroplasties including bilateral procedures were included. Arthroplasty for trauma was excluded.

A total of 12,243 patients underwent hip or knee arthroplasty within the study period. 59% were female and the mean age was 68 (range 21–91). During this time period the standard protocol was to use aspirin for thromboprophylaxis. Eleven patients died following surgery giving a mortality rate of 0.09%. The most common cause of death was myocardial infarction (7/11 patients).

Our finding of a mortality rate of 0.09% is similar or lower to those found in previous studies. To our knowledge this is the first series of this size looking at mortality from hip and knee arthroplasty within a single centre in the UK.

Introduction

This study investigates the effect of somatisation on results of lumbar surgery.

Background: Patients undergoing total knee arthroplasty (TKA) frequently require allogenic blood transfusion. The incidence of blood transfusion varies between 1.4 and 24.5% in the published literature.

Purpose of the study: In order to determine the incidence of allogenic blood transfusion in patients undergoing primary TKA at our centre, we performed retrospective analysis of prospectively collected data for all patients who underwent TKA between 1 April 2006 and 31 March 2008.

Material and Methods: 1488 eligible patients were categorized into two groups: those who underwent TKA in year 2006 (group I, n= 647) and in year 2007 (group II, n = 841), respectively. Patients with haematological diseases, coagulation disorders or with a known malignancy or infection were excluded.

Data were collected for haemoglobin levels (pre-operative, postoperative and predischarge), duration of operation, ASA grade, number of transfusions, use of tranexamic acid and suction drains with relevant clinical data including postoperative medical and surgical complications. Allogenic blood transfusions were administered according to hospital policy. The transfusion threshold was haemoglobin of 8g/dl or less or a symptomatic patient.

Results: The two groups were similar with respect to age, gender, ASA, BMI, duration of operation, pre and post-op haemoglobin and tranexamic acid usage. A significantly greater proportion of patients in group I required allogenic blood transfusion when compared to group II. (4.2% vs. 1.2%, group I vs. group II, p < 0.001; respectively).

In group I, the usage of suction drain was significantly greater when compared to group II (48% vs. 20%, group I vs. group II, p = 0.27 respectively). The medical complications in group I, included superficial wound infections (two patients), myocardial ischemia (one patient) and reversible acute renal failure (one patient), while in group II, one patient developed a superficial wound infection, which was treated with oral antibiotics.

Conclusion: A low rate of allogenic blood transfusion can be achieved by using tranexamic acid and minimising insertion of suction drains. To the best of our knowledge, we report the lowest rate of allogenic blood transfusion for primary TKA. Our data have important implications in the management of patients undergoing TKA.

Purpose: In order to determine the incidence of allogenic blood transfusion in patients undergoing primary total knee arthroplasty (TKA) at our centre, we performed a retrospective analysis of prospectively collected data for all patients who underwent TKA between 1 April 2006 and 31 March 2008.

Methods and Results: In 2006/2007 there were 650 primary TKA patients (group 1) and in 2007/2008 this increased to 841 (group 2). Allogenic blood transfusions were administered according to hospital policy. The transfusion threshold was haemoglobin of 8g/dl or less or a symptomatic patient. For transfused patients data were collected for haemoglobin levels (pre-operative, post-operative and pre-discharge), duration of operation, ASA grade, number of transfusions, use of tranexamic acid and suction drains, and relevant clinical data including post-operative medical and surgical complications.

In group 1 27 patients were transfused (group 1T) and in group 2 10 patients were transfused (group 2T). This was a significant reduction in allogenic blood transfusions (4.5% vs. 1.2%, p < 0.001). The two transfused groups were similar with respect to age, gender, ASA, BMI, duration of operation, pre- and post-operative haemoglobin and tranexamic acid usage. In group 1T, the usage of suction drains was greater than in group 2T (48% vs. 20%) although this was not statistically significant (p = 0.27).

Conclusion: This study indicates that a low rate of allogenic blood transfusion can be achieved by using tranexamic acid and minimising insertion of suction drains. To the best of our knowledge, we report the lowest rate of allogenic blood transfusion for primary TKA. Our data have important implications in the management of patients undergoing TKA, particularly with respect to the need to cross-match all patients.

Purpose: The purpose of this study was to prospectively evaluate a consecutive series of patients receiving metal on metal hip resurfacing arthroplasty with regards to outcomes and complications at minimum of 2 years follow-up.

Method: A prospective evaluation of all patients receiving hip resurfacing was performed including baseline evaluation (demographics, WOMAC, SF12, Oxford Hip Score) and minimum 2 year follow-up assessment (WOMAC, SF12, Oxford Hip Score, UCLA activity score, Patient Satisfaction, Complications). No patients were lost to follow-up.

Results: 143 hips in 127 patients received metal-on-metal hip resurfacing arthroplasty. The mean age was 52 years and the primary diagnosis was osteoarthritis or avascular necrosis, Significant improvements were noticed across all baseline quality of life instruments (p< .05) with final mean WOMAC and Oxford Scores 95 (normalized 0–100). Final post-op satisfaction was mean 95 out of 100. Two patient sustained post-operative femoral neck fractures and required revision. An additional two patients required revision for ongoing hip pain. One patient sustained a sciatic nerve palsty and one additional patient required acetabular component repositioning on the same day as the index procedure. Revision procedures involved conversion of resurfacing femoral component to cementless total hip stem with large diameter metal head and preservation of acetabular component. Acetabular component survivorship is 99% and femoral component survivorship is 97% at 2 year follow-up.

Conclusion: Our short to midterm data, from an independant center, suggests excellent improvement in quality of life with high levels of patient satisfaction and postop acitivity level. Our comprehensive post-operative quality of life assessment demonstrates restoration of the hip to rival that of the normal non-arthritic hip joint. Complications unique to resurfacing arthroplasty occur and were not predictable based on pre-operative or intra-operative patient-specific features.

Introduction: This study investigates the effect of soma-tisation on results of lumbar surgery.

Methods: Pre- and postoperative data of all primary discectomies and posterior lumbar decompressions was prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year.

Results: There were a total of 320 patients (average age 49.7 years). Preoperatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up.

All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively).

At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers.

The postoperative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0).

The postoperative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5).

In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7).

These differences are statistically significant.

Discussion: Patients with features of somatisation are severely functionally impaired preoperatively. One year following lumbar spine surgery, 60%(28) had improved psychologically, 23%(11) were defined as psychologically normal. This was associated with a significant improvement in function and back and leg pain. The 14(30%) patients who did not improve psychologically and remained somatisers had a poor functional outcome. Our results demonstrate that psychological distress is not an absolute contraindication to lumbar spinal decompressive surgery.

Background: Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures.

Methods: Using the hip fracture registry at this institution 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year.

Results: Of 100 patients treated operatively, 59 were treated with 1350 sliding hip screws (SHS), 22 were treated with 1350 sliding hip screw devices designed to resist medialization (3 sliding hip screws with trochanteric plate and 19 Medoff plates), and 19 were treated with intramedullary sliding hip screw devices (1 short Gamma nail, 9 long Gamma nails, 6 Reconstruction nails, 6 long Targon nails, 1 short Targon nail). The SHS had 4 failures (6.8%), and the intramedullary devices one failure (5.3%). Those extramedullary devices augmented to prevent medialization had higher failure rates (1 of 3 SHS with trochanteric plate and 3 of 19 Medoff plates), with combined failure rate of 15.8%.

Conclusion: The 1350 SHS and the intramedullary devices had similar failure rates of 6.8% and 5.2% respectively. Those extramedullary devices designed to prevent medialization had higher failure rates (combined failure rate of 4/22 or 18%). This is similar to the high failure rate in 950 devices reported elsewhere. This suggests that extramedullary devices attempting to combat the difficult biomechanics of these fractures are unsuccessful. Better results can be obtained by using the standard 1350 SHS or with intramedullary sliding hip screw devices.

Previous studies on the timing of hip fracture surgery provide limited and conflicting evidence as to whether early operative intervention influences length of hospital stay, functional outcome and mortality rate. The aim of this study was to determine in a large, consecutive and prospectively followed group of patients the effect of a delay to surgery other than for medical reason. Patients who met the following criteria were included in the study: 1) Fragility fracture of the proximal femur. 2) Age over 60. 3) Complete data sets. 4) Complete follow up. Excluded patients were: 1) Younger than 60 years of age. 2) Conservative fracture treatment. 3) Pathological fracture. 4) Delay from admission to surgery for any medical reason. All patients were subdivided into six groups according to the delay between admission and operation (A:1–12 hours, B:13–24 hours, C:25–36 hours, D:37–48 hours, E:49–72 hours, F:73 + hours). All patients were followed up for one year or until death. Data on the mean length of hospital stay and the discharge destination as a parameter for the functional outcome were analysed in each of the six groups. A total of 3628 patients met the inclusion criteria. The average age was 81 years. 95.2% of patients were operated on between 1 and 48 hours after the admission, and 4.8% between 49 or more hours after the admission. Reason for delay was either lack of theatre time or unavailability of a surgeon or an anaesthetist. Statistical analysis with the unpaired t-test showed a significant difference in the hospital length of stay of 21 days for patients operated within 48 hours of admission versus 32 days for patients operated after 48 hours (p The functional outcome was significantly worse in the group with a delay of more than 48 hours with only 71% of patients discharged to their own home (86% in the early group, p< 0.0001). This study provides further and conclusive evidence that early operative intervention in elderly patients with fragility fractures of the proximal femur results in a decreased hospital stay and a better functional outcome.