Recent interest has focused on minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary programme for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service.

The programme involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d'Aubigné clinical rating system and Visual Analogue Pain Scores. Thirty seven patients underwent total hip replacement using the new protocol.

The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d'Aubigné scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new programme allows patients undergoing total hip replacement to be discharged after 1 night post-operatively without compromising safety or quality of care.

Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive programme.

This study aims to assess prospectively whether measurement of perioperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.

All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T >0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p<0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p<0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (7.6%) in the group with no rise (p<0.05).

The principal causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity.

We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.

This study aims to assess prospectively whether measurement of peripoperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.

All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p< 0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), versus 5 (10.6%) in the group with no rise (p< 0.05).

The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.

Introduction: Recently there has been much interest in minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary program for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service.

Methods: The program involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was too early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d’Aubigne clinical rating system and Visual Analogue Pain Scores.

Results: Thirty seven patients underwent total hip replacement using the new protocol.

The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d’Aubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new program allows patients undergoing total hip replacement to be discharged after 1 night post operatively without compromising safety or quality of care.

Conclusion: Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive program.

Introduction: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive and specific enzymatic marker of myocardial injury. This study aims to assess prospectively whether Troponin T may be used as a predictor of morbidity and mortality in admissions with fractured neck of femur.

Methods: All patients aged 65 years and over presenting with a fractured neck of femur over 4 months were included. Exclusion criteria of polymyositis, renal failure and conservative fracture management were applied. Troponin T levels were measured on admission, and days 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures were defined as adverse cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

Results: 108 patients were recruited over the 4 months. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least one of the outcome complications including death, as opposed to 7 (10.6%) from the group with no Troponin rise (p< 0.001). The mean inpatient stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (10.6%) in the group with no rise (p< 0.05).

Discussion: The association between raised Troponin and hip fractures has not previously been made. Many patients appear to be having silent cardiorespiratory or related events, which may be a significant cause of perioperative morbidity and mortality. We propose measurement of Troponin levels as part of the standard perioperative screening for hip fracture patients to identify this risk and initiate appropriate treatment measures.

Introduction: High-frequency ultrasound is an effective mechanism for coagulating and cutting tissue. We report the first use of the ultrasonic scalpel in orthopaedic surgery, with the aim of minimising blood loss and tissue trauma in minimally invasive total hip replacement.

Methods: This is a prospective, single-blind, case-matched study to compare blood loss in minimally invasive total hip replacement using an ultrasonic scalpel versus electrodiathermy. Twenty cases have been performed via a minimally invasive posterior approach. The treatment was otherwise no different between the two groups. The groups were compared with regard to blood loss, post-operative pain and wound healing.

Results: The mean intra-operative blood loss in the ultrasonic scalpel group was 242mls compared with 319mls in the electrodiathermy group. This is statistically significant (p < 0.05). The percentage drop in Haemoglobin was also reduced in the ultrasonic scalpel group (18.9% compared with 26.4%), which is also statistically significant (P< 0.01). There was no significant difference in the operating time or post-operative pain scores and there were no wound complications in either group.

Discussion: The ultrasonic scalpel works by converting electrical energy into mechanical energy resulting in longitudinal oscillation of the blade at 55,500Hz. This achieves coagulation and tissue dissection at lower temperatures than standard diathermy. The potential advantages include less lateral tissue damage, minimal smoke and no electrical energy passed to or through the patient. With the development of minimally invasive hip replacement surgery this technique can be used to reduce tissue trauma. The initial results from this study suggest that the ultrasonic scalpel has a useful role in minimally invasive hip replacement surgery in terms of reducing blood loss and tissue trauma. This may help to facilitate early mobilisation and reduced hospital stay.

Introduction Total hip replacement is the commonest arthroplasty procedure performed in the UK. The in-patient stay has gradually reduced and patients now typically spend five to seven days in hospital. We have developed a new multidisciplinary protocol for patients undergoing total hip replacement in order to facilitate early discharge.

The aims of this study were to prospectively assess whether this new protocol could be safely applied to patients undergoing total hip replacement and whether it reduced length of stay.

Methods The protocol involved a pre-operative program of education and physiotherapy, a modified anaesthetic regime, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged to an outreach team support network. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle dAubigne clinical rating system and Visual Analogue Pain Scores.

Results Twenty-five patients underwent total hip replacement using the new protocol. All patients were discharged home within 48 hours of surgery. There were two unplanned reattendances neither of which required readmission. The mean pain score on discharge was 3/10. The Oxford Hip Questionnaire and Merle dAubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol.

Discussion Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for rehabilitation. It may also help to improve efficiency and alleviate pressure on an overburdened health service. This new protocol allows patients undergoing total hip replacement to be discharged within 48 hours of undergoing surgery without compromising safety or quality of care.

Introduction High-frequency ultrasound is an effective mechanism for coagulating and cutting tissue. We report the first use of the ultrasonic scalpel in orthopaedic surgery, with the aim of minimising blood loss and tissue trauma in minimally invasive total hip replacement.

Methods This is a prospective, single-blind, case-matched study to compare blood loss in minimally invasive total hip replacement using an ultrasonic scalpel versus electrodiathermy. Twenty cases have been performed via a minimally invasive posterior approach. The treatment was otherwise no different between the two groups. The groups were compared with regard to blood loss, postoperative pain and wound healing.

Results The mean intraoperative blood loss in the ultrasonic scalpel group was 156mls compared with 295mls in the electrodiathermy group. This is highly statistically significant. The percentage drop in Haemoglobin was also reduced in the ultrasonic scalpel group (18.9% compared with 26.4%), which is also statistically significant. There was no significant difference in the operating time or post-operative pain scores and there were no wound complications in either group.

Discussion The ultrasonic scalpel works by converting electrical energy into mechanical energy resulting in longitudinal oscillation of the blade at 55,500Hz. This achieves coagulation and tissue dissection at lower temperatures than standard diathermy. The potential advantages include less lateral tissue damage, minimal smoke and no electrical energy passed to or through the patient. With the development of minimally invasive hip replacement surgery this technique can be used to reduce tissue trauma.

Conclusion The initial results from this study suggest that the ultrasonic scalpel has a useful role in minimally invasive hip replacement surgery in terms of reducing blood loss and tissue trauma. This may help to facilitate early mobilisation and reduced hospital stay.

Aims: Schuss radiographs are PA weight bearing views of the knee taken in 30 degrees of ßexion. Several studies have shown them to be more sensitive detectors of osteoarthritic changes in the knee than standard extension AP views. The aim of this study was to determine whether the increased severity of degenerate change shown on these radiographs is sufþcient to alter proposed orthopaedic management of patients. Methods: Fifty consecutive patients aged 45–75 presenting to clinic with symptoms suggestive of tibiofemoral osteoarthritis were included. Each underwent standard clinical assessment and weight bearing extension AP and lateral radiographs of the knee. In addition a digital photograph of the legs and a single schuss radiograph were taken. This information was collated onto slides, two per patient. One slide included the history and examination þndings plus the photograph, extension AP and lateral radiographs. The other was identical save that the extension AP was replaced by the schuss radiograph. The slides were randomised and shown to eight consultant orthopaedic surgeons. For each slide each consultant was asked to give his preferred management. Responses for the two slides of each patient were compared. Results: The panel changed their management plan in over 40% of cases. This represented a reduction of almost 50% in arthroscopies in the schuss group with a move towards deþnitive surgery. Total number of procedures proposed was also reduced. Conclusion: The schuss radiograph is a valuable tool in the assessment of knee osteoarthritis the use of which can alter clinical management. By reducing non-therapeutic arthroscopies it may signiþcantly reduce total number of operations to be performed in this patient group.

Schuss radiographs are PA weight bearing views of the knee taken in 30 degrees of flexion. They are more sensitive detectors of osteoarthritic changes in the knee than standard extension AP views.

Aim of this study was to determine whether the increased severity of degenerate change shown on these radiographs is sufficient to alter proposed orthopaedic management of patients.

Methods: fifty consecutive patients aged 45–75 presenting to clinic with symptoms suggestive of tibiofemoral osteoarthritis were included. Each underwent standard clinical assessment and weight bearing extension AP and lateral radiographs of the knee. In addition a digital photograph of the legs and a single schuss radiograph were taken. This information was collated onto slides, two per patient. One slide included the history and examination findings plus the photograph, extension AP and lateral radiographs. The other was identical save that the extension AP was replaced by the schuss radiograph. The slides were randomised and shown to eight consultant orthopaedic surgeons. For each slide each consultant was asked to give his preferred management. Responses for the two slides of each patient were compared.

Results: The panel changed their management plan in over 40% of cases. This represented a reduction of almost 50% in arthroscopies in the schuss group with a move towards definitive surgery. Total number of procedures proposed was also reduced.

Conclusions: The schuss radiograph is a valuable tool in the assessment of knee osteoarthritis which can alter clinical management. By reducing non-therapeutic arthroscopies it may significantly reduce total number of operations to be performed in this patient group.