Aims

A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be “high-risk” with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients.

Aims

Our aim was to report survivorship data and lessons learned with the Corail/Pinnacle cementless total hip arthroplasty (THA) system.

Ideal placement of the acetabular component remains elusive both in terms of defining and achieving a target. Our aim is to help restore original anatomy by using the transverse acetabular ligament (TAL) to control the height, depth and version of the component. In the normal hip the TAL and labrum extend beyond the equator of the femoral head and therefore, if the definitive acetabular component is positioned such that it is cradled by and just deep to the plane of the TAL and labrum and is no more than 4mm larger than the original femoral head, the centre of the hip should be restored. If the face of the component is positioned parallel to the TAL and psoas groove the patient specific version should be restored. We still use the TAL for controlling version in the dysplastic hip because we believe that the TAL and labrum compensate for any underlying bony abnormality.

The TAL should not be used as an aid to inclination. Worldwide, > 75% of surgeons operate with the patient in the lateral decubitus position and we have shown that errors in post-operative radiographic inclination (RI) of > 50° are generally caused by errors in patient positioning. Consequently, great care needs to be taken when positioning the patient. We also recommend 35° of apparent operative inclination (AOI) during surgery, as opposed to the traditional 45°.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):37–43.

Ceramic-on-metal (CoM) is a relatively new bearing combination for total hip arthroplasty (THA) with few reported outcomes. A total of 287 CoM THAs were carried out in 271 patients (mean age 55.6 years (20 to 77), 150 THAs in female patients, 137 in male) under the care of a single surgeon between October 2007 and October 2009. With the issues surrounding metal-on-metal bearings the decision was taken to review these patients between March and November 2011, at a mean follow-up of 34 months (23 to 45) and to record pain, outcome scores, radiological analysis and blood ion levels. The mean Oxford Hip Score was 19.2 (12 to 53), 254 patients with 268 hips (95%) had mild/very mild/no pain, the mean angle of inclination of the acetabular component was 44.8^o (28^o to 63^o), 82 stems (29%) had evidence of radiolucent lines of > 1 mm in at least one Gruen zone and the median levels of cobalt and chromium ions in the blood were 0.83 μg/L (0.24 μg/L to 27.56 μg/L) and 0.78 μg/L (0.21 μg/L to 8.84 μg/L), respectively. The five-year survival rate is 96.9% (95% confidence interval 94.7% to 99%).

Due to the presence of radiolucent lines and the higher than expected levels of metal ions in the blood, we would not recommend the use of CoM THA without further long-term follow-up. We plan to monitor all these patients regularly.

Cite this article: Bone Joint J 2015;97-B:300–5.

With greater numbers of younger patients undergoing total hip replacement (THR), the effect of patient age on the diameter of the femoral canal may become more relevant. This study aimed to investigate the relationship between the diameter of the diaphysis of the femoral canal with increasing age in a large number of patients who underwent THR. A total of 1685 patients scheduled for THR had their femoral dimensions recorded from calibrated radiographs. There were 736 males and 949 females with mean ages of 67.1 years (34 to 92) and 70.2 years (29 to 92), respectively. The mean diameter of the femoral canal was 13.3 mm (8.0 to 23.0) for males and 12.7 mm (6.0 to 26.0) for females. There was a poor correlation between age and the diameter of the canal in males (r = 0.071, p = 0.05) but a stronger correlation in females (r = 0.31, p < 0.001).

The diameter of the femoral canal diameter of a female patient undergoing THR could be predicted to increase by 3.2 mm between the ages of 40 and 80 years, in contrast a male would be expected to experience only a 0.6 mm increase during the same period. This increase in the diameter of the canal with age might affect the long-term survival of the femoral component in female patients.

Cite this article: Bone Joint J 2013;95-B:339–42.

Restoration of leg length and offset is an important goal in total hip replacement. This paper reports a calliper-based technique to help achieve these goals by restoring the location of the centre of the femoral head. This was validated first by using a co-ordinate measuring machine to see how closely the calliper technique could record and restore the centre of the femoral head when simulating hip replacement on Sawbone femur, and secondly by using CT in patients undergoing hip replacement.

Results from the co-ordinate measuring machine showed that the centre of the femoral head was predicted by the calliper to within 4.3 mm for offset (mean 1.6 (95% confidence interval (CI) 0.4 to 2.8)) and 2.4 mm for vertical height (mean -0.6 (95% CI -1.4 to 0.2)). The CT scans showed that offset and vertical height were restored to within 8 mm (mean -1 (95% CI -2.1 to 0.6)) and -14 mm (mean 4 (95% CI 1.8 to 4.3)), respectively.

Accurate assessment and restoration of the centre of the femoral head is feasible with a calliper. It is quick, inexpensive, simple to use and can be applied to any design of femoral component.

The angle of inclination of the acetabular component in total hip replacement is a recognised contributing factor in dislocation and early wear. During non-navigated surgery, insertion of the acetabular component has traditionally been performed at an angle of 45° relative to the sagittal plane as judged by the surgeon’s eye, the operative inclination. Typically, the method used to assess inclination is the measurement made on the postoperative anteroposterior radiograph, the radiological inclination.

The aim of this study was to measure the intra-operative angle of inclination of the acetabular component on 60 consecutive patients in the lateral decubitus position when using a posterior approach during total hip replacement. This was achieved by taking intra-operative photographs of the acetabular inserter, representing the acetabular axis, and a horizontal reference. The results were compared with the post-operative radiological inclination.

The mean post-operative radiological inclination was 13° greater than the photographed operative inclination, which was unexpectedly high. It appears that in the lateral decubitus position with a posterior approach, the uppermost hemipelvis adducts, thus reducing the apparent operative inclination. Surgeons using the posterior approach in lateral decubitus need to aim for a lower operative inclination than when operating with the patient supine in order to achieve an acceptable radiological inclination.