Objectives: To compare the results of various surgical approaches to the knee in primary arthroplasty surgery.

Design: Systematic review with meta-analysis

Data Sources: Cochrane Bone, Joint, and Muscle Trauma group trials register (2007), Cochrane central register of controlled trials (Cochrane Library issue 2, 2007), Medline (1950 to February 2007), Embase (1974 to February 2007), CINAHL (1982 to February 2007), Pubmed, SCOPUS and ZETOC. If data was insufficient trialists were contacted via telephone, email or letter.

Review methods: Randomised and quasi-randomised controlled trials comparing surgical approaches to the knee in patients undergoing primary arthroplasty surgery.

Results: Twenty-three randomised, controlled trials (1282 patients, 1490 TKAs) were included.

Midvastus vs Medial Parapatellar approach: Quadriceps function in the early post operative period was better preserved in the MV group. Post operative pain, blood loss and the need for LRR tended to be lower in the MV group. There was no difference in ROM, hospital stay, knee scores, complications or radiological alignment.

Conclusions: Approaches preserving the quadriceps tendon improve the early extensor mechanism function and tend to decrease the need for LRR. Combined with a decrease blood loss and postoperative pain, these approaches improve early rehabilitation and allow for a more rapid recovery of knee function. However, these early improvements fail to provide any long term benefit, do not improve knee scores, or decrease the length of hospital stay.

Introduction: With the rising number of primary hip arthroplasties performed each year, patient selection criteria is becoming increasingly pertinent. There is growing concern that patients with a high body mass index (BMI) have worse outcomes following hip replacement surgery. However the evidence base is equivocal.

Our aim is to assess whether BMI has an impact on clinical and radiological outcomes of primary total hip arthroplasties

Methods: This is a prospective study of 92 patients, undergoing primary total hip arthroplasty, recruited from two hospitals. Data was collected by the operating surgical team and independent physiotherapists at the preoperative assessment clinic, intraoperatively and at six weeks post-operative follow up.

BMI was recorded. Patients were divided into 2 groups: those with a BMI less than 30 (considered nonobese) and those 30 or above (obese).

Outcomes assessed included blood loss and requirement blood transfusion, fat thickness, operation duration, complications and surgeon’s perception of the difficulty of operation (scored on a VAS). In addition functional capacity was assessed using the Oxford Hip scores pre and post-operatively. Radiographs were scored independently according to Dorr and Barrack.

Results: Of our 92 patients, 36 were obese and 56 were non-obese. There was no significant difference found in blood loss, blood transfusion requirements, operation duration and complications between the two groups, With regards to the Oxford Hip scores, the obese patients had greater differences between their pre- and post-operative scores but this difference was not significant (p=0.09). We found a significant difference (p=0.003) in surgeons’ perception of the difficulty of operation with VAS scores for obese patients being higher than non-obese patients. Our Dorr and Barrack scores revealed no significant difference in radiological outcome between our two groups.

Conclusion: Our study would suggest that obese patients do not have worse outcomes following primary total hip arthroplasty than non-obese patients.

Study Design: A prospective randomised controlled trial.

Objective: The early management of acute soft tissue injuries of the neck remains controversial. The aim of this study was to compare an early mobilisation regime versus with treatment with a soft collar for recovery of function and activity levels after soft tissue injuries of the neck.

Subjects: Over a one year period, 108 patients presenting with a soft tissue neck injury were enrolled in a prospective trial. Each patient was randomised to either early mobilisation using an exercise regime (55 patients) or 3 weeks treatment in a soft collar followed by the same exercise regime (53 patients). Patients were followed up at 3, 12 and 52 week intervals from injury.

Outcome Measures: Visual Analogue Scores for pain, range of neck movements, activities of daily living and time taken to return to work.

Results: No differences were found between the two groups for pain, range of neck movements or for activities of daily living at any of the follow up intervals. The collar treatment group took significantly longer to return to work after injury (21 days) compared to the early mobilisation group (9 days), p< 0.05.

Conclusions: Treatment in a soft collar had no clinical benefit compared to early mobilisation in terms of recovery of function, pain or range of neck movements, but was associated with an increased time to return to work.

The best management of displaced intracapsular femoral neck fractures in the elderly remains undecided. Most are treated by hemiarthroplasty. The aim of this study was to establish whether the advantages of cement outweigh the disadvantages.

All patients with displaced intracapsular femoral neck fractures treated with herniarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used, but in hospital A they were uncemented, and in B cemented. There were 122 patients in hospital A and 123 in B. We conducted a detailed retrospective analysis of hospital notes. All surviving patients (50 and 56 respectively) were interviewed to obtain pre-fracture and current scores of pain, walking ability, use of walking aids, activities of daily living (ADL) and accommodation status, using validated scoring systems. The relative deterioration over the follow-up period (32–36 months) was determined and the groups compared.

Patient demographics confirmed comparability of groups. There was no greater incidence of intra-operative fall in diastolic blood pressure, or oxygen saturation in the cemented group. Cemented procedures were on average 15 minutes longer. Median in-patient stay was the same. Significantly fewer of the cemented group had been revised or were awaiting revision (p=0. 036). There was no difference in mortality rates at any point between surgery and follow-up. Prospective assessment of surviving patients revealed highly statistically significant greater deterioration in pain (p=0. 003), walking ability (p=0. 002), use of walking aids (p=0. 003) and ADL (p=0. 009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical significance (p=0. 14).

In conclusion, the cemented group faired significantly better than the uncemented group. Our findings suggest the advantages of cement outweigh the disadvantages, and we support the use of cemented hemiarthroplasty for the displaced intracapsular femoral neck fracture in the elderly patient.