Aim: To determine whether operator’s experience and time of operation (MUA) affects the outcome of fractures in paediatric age group as measured by re-MUA rate.

Method: Retrospective analysis of 918 children with fractures requiring MUA over a period of eight years was carried out.

Results: Re-MUA rate for those 910 children was 9.8%(90). There was a significant difference in these fractures requiring re-MUA depending upon the operator’s experience and time. Amongst all (90) who required re-MUA 7(7.7%) had index surgery by consultants and 83(93.3%) had MUA by trainee surgeons. 23(17.4%) patients were operated between 9 to 1700 hours and rest of them had MUA after 1700 hours (82.6%). At repeat procedure 4(4.4%) required some sort of fixation. (K wiring or ORIF)

Conclusion: The current overall re-MUA rate is higher than data published from the specialised centres and surgeons, but is probably more representative of norm, when performed in a general setting. Exact fracture personality should be evaluated carefully to reduce re-MUA rate. Re-MUA rate for trainee needs to be improved.

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches.

Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS.

AIM: To find out the affect of surgical approach on oxford hip score.

Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem AND were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS.

Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively.

CONCLUSION: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients.

The optimal surgical approach for total hip replacement (THR) remains controversial. We report the clinical outcomes of over 1000 patients in the Exeter primary outcomes study (epos) who underwent primary THR with a cemented Exeter stem (Stryker) but with various acetabular components. This was a prospective non randomised multi centre study. Patient reported hip scores (oxford hip score (OHS)) were measured before operation and at 3 months (n= 1312), 1 (n=1276), 2 (n= 1225), 3 (n=1205) and 4 (n=975) years post operatively. Physician reported scores (Merle d’Aubigne / Postel, MDAP) were measured before operation and at 12 months. All of the operations were carried out using either the anterolateral (Hardinge or modification) or posterior approach.

The posterior approach gave better absolute OHS scores at 3 months and 1 year compared with the anterolateral approach. The improvement in OHS between the pre-op and relevant post-op score was better for the posterior than the Hardinge approach, and this extended to 4 years (all p< 0.05). Early dislocation rates were low in both groups. There was significantly more likely to be heterotopic ossification in the Hardinge group, while stem alignment into varus was more common in the posterior approach group. There was no significant difference between the two approaches as measured using the MDAP score at pre-op or at 12 months after surgery.

These results demonstrate that initial patient perceived clinical benefit of surgery is greater using a posterior than with an anterolateral approach. This should be considered when assessing the best approach for a particular patient. The current results emphasise the value of using patient based outcome measures, as the MDAP score did not detect a difference in outcomes between the two groups.

There has been controversy about whether limb length discrepancy (LLD) affects outcome after total hip replacement (THR). We examined input variables and outcomes of over 1200 patients who received primary THR with the Exeter stem and a variety of acetabular components in the Exeter Primary Outcomes Study. This was a non randomized prospective multi centre study.

We examined whether specific groups of patients or surgeons were more likely to have LLD at one year after surgery. Data for leg length measured on clinical assessment were available for 1207 patients at 1 year. 237 patients were recorded as having a leg length difference of 1 cm or more, and 73 a difference of 2 cm or more. 138 were longer on the operated side and 99 were shorter. The likelihood of having LLD of 2 cm or more was not significantly affected by the grade of surgeon (consultant or trainee), BMI, age of patient, position of patient during surgery or surgical approach, or the use of regional or general anaesthetic.

We examined the effect of LLD on outcomes at 3 months and 1,2,3 and 4 years. Patients with LLD > 1cm had significantly worse Oxford Hip Scores (OHS) at 1, 2, 3 and 4 years (p< 0.01), with the OHS generally being an average 2 points worse in those with LLD. The most consistent difference between those with and without LLD was a patient reported limp on the Oxford Hip Questionnaire.

We conclude that LLD is a common problem after THR and that all patient groups may be affected. It is associated with a significantly worse functional outcome as measured by a validated hip score. Systematic adoption of accurate intra-operative measures of leg length might pay dividends in minimizing this complication.