Aim

The purpose of this study was to quantify the number of children treated with ESIN (elastic stable intra-medullary nails) at our institution and to determine what proportion of these nails have been removed and the time and difficulty taken to do so.

Purpose of study: To evaluate the clinical outcome of operative intervention for chronic patellar instability for patients treated by a single paediatric orthopaedic surgeon over a 74-month period

Method: There were 11 patients (16 knees) with a mean age at operation of 11.9 years (5 to 17 years). Patients were treated with combined proximal and distal patellar realignment. Mean follow-up was 44.6 months (11–86 months). All patients were assessed post-operatively with satisfaction scores, the Trillat grading system and the Activity Scale for Kids (ASK). They were also questioned specifically for patellofemoral symptoms and examined for signs of mal-tracking.

Results: Subjective patient rating of all procedures revealed 10 (62.5%) responses of excellent or very good, 4 (25%) good, 1 (6.25%) fair and 1 poor (6.25%). Formal Trillat grading revealed 9 (56.3%) excellent, 6 (37.5%) good, 1 (6.2%) fair and no poor outcomes. The mean ASK score was 82% (39–100%). All except one patient felt that they would choose to undergo the surgery again. There was one complication of a superficial wound infection.

Conclusions: These results show improvement in symptoms and function as judged by Trillat grading and a majority of patients satisfied with the results of the procedure. We feel that the advantage of appropriate surgical intervention at a young age is not only the improvement in symptoms, but also that successful realignment of patellar tracking may reduce subsequent degenerative problems associated with chronic instability and allow better rehabilitation of the dynamic stabilisers of the patellofemoral joint.

Cementless total hip replacements (THR) have a theoretical advantage over cemented designs in that bone lysis and probably aseptic loosening are less common complications. NICE guidelines suggest that prosthesis should have an aseptic loosening rate of < 10% at 10 years. Long-term follow-up of the Joint Replacement Instrumentation (JRI) Hydroxyapatite coated (HAC) Furlong system is gradually emerging following its first clinical application in 1985.

A retrospective study was performed to identify all patients having undergone a primary JRI HAC THR under a single Consultant at Barnsley Foundation Hospital NHS Trust between 1985 and 1995. This identified 124 joints in 106 patients (52% males). All living patients were sent a modified Oxford Hip Score questionnaire; case notes were also reviewed to identify any revision surgeries.

Median age at operation was 54.0 years. 17 patients (16%) had died at the time of this study. Median follow-up was 13.7 years (range 9.4–18.5 years). For 30 patients (24.2%) it was impossible to gather data on the survival of the hip.

Mean survival of all hips followed up was 16.2 years. Twenty-four hips (19.4%) required revision surgery; the median time to this surgery was 10.2 years, mean 8.2 years. Reasons included aseptic loosening of the stem in one patient at 12.7 years, aseptic loosening of the cup in 7 patients (range 10.2–17.4 years), worn polythene insert in 4 patients, infective loosening in 3 patients and recurrent dislocations in 2 patients. The remainder of revisions were for unknown reasons.

The Oxford Hip Score postal questionnaire was returned by 79% of patients. Mean score was 12.6/45 but 88% of patients reported overall satisfaction with the hip.

In summary, there were no revision surgeries at ten-year follow-up for aseptic loosening.

Total hip arthroplasty (THA) patients often require peri-operative blood transfusion. Variables that predict transfusion requirement may allow us to target cross-matching of individual patients.

153 patients underwent primary unilateral THA for osteoarthritis or rheumatoid arthritis during 2002 in our institution. 75 casenotes from these subjects were reviewed. Age, sex, diagnosis, weight, height, pre-operative haemoglobin (Hb) and haematocrit (Hct), anticoagulation type and timing were recorded, along with post-operative Hb and timing and quantity of any blood transfusion. Potential predictors of transfusion were examined using logistic regression analysis. ROC analysis was used to compare the relative predictive value of significant variables.

Mean (±SD) age at surgery was 67±11 years (53% females). Mean pre-operative Hb was 13.8±1.4g/dl, mean post-operative Hb was 10.2±1.0g/dl. 27 patients (36%) needed a transfusion; the most frequently given volume was 2 units and the mean number of units given was 0.85. The most common reason for transfusion was an asymptomatic low Hb (< 8.0g/dl). Pre-operative Hb and Hct were predictive of post-operative transfusion (logistic regression analysis P< 0.01). Age, gender, diagnosis and anticoagulation were not predictive. Using ROC analysis the optimal ‘cut-off’ value of pre-op Hb as a predictor was 12.7 g/dl, giving a sensitivity of 41% and a specificity of 88% for blood transfusion requirement. The optimal ‘cut-off’ for Hct was 0.41, sensitivity 74% and specificity 61%. There was no significant difference in the overall predictive value between these variables (comparison of area under ROC curves, P> 0.05).

In summary, subjects with a pre-operative Hb< 12.7 or Hct < 0.41 are more likely to require a blood transfusion after unilateral primary THA than those with an Hb or Hct above these values. In treatment centres where cross-matched blood is not available at short notice on demand, pre-operative cross-match of patients with blood counts below these values may be appropriate.