Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

Enhanced recovery programmes have improved outcomes following elective arthroplasty surgery. Most studies assess whole advanced recovery programmes. There are few studies assessing the role of patient education. We therefore assessed our outcomes.

As part of our enhanced recovery programme at Wrexham Maelor Hospital, all patients are offered the chance to attend ‘joint school’, a preoperative education class. Not all patients attend these sessions allowing comparison of outcomes in these two groups using our prospectively collected database of outcome measures.

Between April 2009 and March 2013, 915 patients underwent elective hip or knee arthroplasty. Revision cases were excluded, leaving 567 knee replacements, 315 hip replacements and 27 unicompartmental knee replacements.

In patients undergoing knee replacement, those attending joint school had shorter length of stay (4.38 vs 4.85 days, p=0.145) and better Oxford Knee Score at 6 months (p=0.026) and two years (p=0.035). Patients undergoing total hip arthroplasty had a statistically significantly shorter length of stay (3.64 vs 4.54 days, p=0.011); increased frequency of mobilising on the day of surgery (28.1% vs 22.6%, p=0.203) and higher Oxford Hip Scores (non-significant) if they attended joint school.

Our retrospective analysis demonstrates that preoperative education for patients undergoing elective total hip arthroplasty produces significantly shorter lengths of stay. There are also effects on mobilisation and outcome scores. These effects are also seen in knee arthroplasty. These results will have clinical and financial implications. Assessing cost of saved bed days alone, joint school saves the trust over £10,000 per year.

The management of pelvic fractures remains a challenging problem for orthopaedic surgeons. The prompt recognition of unstable fracture patterns is important in reducing mortality and morbidity. It is perceived wisdom that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. There is a paucity of evidence in the literature to support this belief. The aim of our study was to determine if a fracture of the transverse process of L5 was a predictor of pelvic fracture instability.

The Hospital Trauma database was reviewed. Between 2006 and 2009, 65 pelvic fractures were identified. They were classified according to the Burgess and Young classification. There were 37 stable and 28 unstable fractures. 14 patients had an associated fracture of the transverse process of L5; 9 were associated with an unstable fracture pattern. The odds ratio was 3; the relative risk 1.7.

A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury.

The management of pelvic fractures remains a challenging problem for orthopaedic surgeons. The prompt recognition of unstable fracture patterns is important in reducing mortality and morbidity. It is perceived wisdom that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. There is a paucity of evidence in the literature to support this belief. The aim of our study was to determine if a fracture of the transverse process of L5 was a predictor of pelvic fracture instability.

The Hospital Trauma database was reviewed. Between 2006 and 2009, 65 pelvic fractures were identified. They were classified according to the Burgess and Young classification. There were 37 stable and 28 unstable fractures. 14 patients had an associated fracture of the transverse process of L5; 9 were associated with an unstable fracture pattern. The odds ratio was 3; the relative risk 1.7.

A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury.

The Quebec Task Force defined whiplash as “an acceleration–deceleration mechanism of energy transfer to the neck”. It is logical that the lower the velocity change following impact, the lower the risk of injury. The accepted velocity change (delta-v) for whiplash injuries following rear impact has been quoted as 5 mph. There is some debate as whether this is valid in the clinical setting. We aimed to investigate this further.

A series of low speed controlled crash simulations were undertaken. There were a total of 27 runs on 23 individuals. Accelerometers were placed on the head and chest of the volunteers. Video recordings were analysed to assess relative displacement of the head and chest. The presence of symptoms was documented over a period of 7 days. The volunteers consisted of 23 males and 1 female with an average age of 38 (range 20–56). The average delta-v achieved was 2.3 mph (range 1.8–3.1 mph). The average maximum accelerations recorded were 3.46g at the chest and 2.93g at the head. The average difference was 0.53g. There was no significant displacement between the head and body. No symptoms were reported beyond 1 hour.

Whiplash is triggered if the disparity between movements of the head and neck is of sufficient magnitude. It seems logical that there is a threshold below which whiplash will not occur. Our results have shown that below a delta-v of 3 mph there is little difference in the magnitude and timing of the movements of the head and chest.

Therefore the whiplash mechanism of injury does not occur at these changes of velocity.

Introduction: The national comparative audit in 2007 of blood use in primary elective hip replacement, showed a 25% transfusion rate. Of those 93% received two or more units. Orthopaedic surgeons are large users of blood, so reducing blood use, should save costs and reduce risk from unnecessary donor exposure.

Methods: Over two years 221 consecutive primary total hip replacements were performed, on 84 male and 137 female patients, average age 70 years (42–91yrs). For each the Haematinics cell salvage system was used. Throughout the surgery the cell salvage system was used. At the end of the operation all swabs were washed, the washings were salvaged. Iodine/peroxide contaminated washing and swabs were discarded.

Results: Were we using blood at the level suggested by the comparative audit, 55 patients would have received an average of 2.4 units (132 units total). The actual number of patients transfused was 12, receiving an average of two units (24 units total). This is 108 units less with 43 fewer patients receiving allogenic blood. Using a test of proportions using the Normal distribution then the significance probability is extremely small (SP< 0.001) indicating that this group of patients had a significantly smaller number of transfusions than would be expected compared with the National Average. The transfused patients were older (78.9 vs. 69.8, p< 0.01), had a greater Hb drop (45 g/l vs. 31.2 g/l, p< 0.01), had a lower pre-op Hb (121.3 g/l vs. 138 g/l, p< 0.001), and a greater length of stay (12.8 days vs. 5.8 days, p< 0.05). Gender was not significant.

Discussion: Using the cell salvage system leads to a significant reduction in allogenic blood use. It may not be cost neutral once the use of disposables is factored in, but may represent a useful tool to cost effectively reduce allogenic blood use.

Purpose: To examine the outcome of primary and revision knee arthroplasty in very elderly patients.

Methods and Results: Patients in their 90th year of life who underwent primary or revision knee arthroplasty between January 2000 and September 2007 were identified. Data was collected regarding demographics, ASA grade, co-morbid factors, complications, length of inpatient stay, the need for transfusion and discharge destination. Thirty day, 1 year and current mortality figures were calculated.

Twenty one procedures were performed on 18 patients with a mean follow up of 18.8 months (3–57.9). There were 14 primary total knee replacements and 7 revision procedures. The mean age at the time of surgery was 90 years and 10 months (89 years 1 month to 94 years 4 months). The majority of patients were female (15). All patients were ASA grade 2 or 3. The average orthopaedic inpatient stay was 17 days. Thirty percent of patients required a period of further inpatient rehabilitation or convalescence after discharge from our institution. Nine patients experienced a post-operative complication. Mortality at 30 days was 0%, at 1 year 6% (1/16), and is currently 17% (3/18).

Conclusion: Very elderly patients are able to tolerate primary and revision knee arthroplasty although there is a high rate of peri-operative complications. We propose that there should be a different tariff for arthroplasty procedures in extremely elderly patients to reflect the increased rate of complications and prolonged postoperative hospital stay.

Introduction: Antibiotic-associated Clostridium difficile diarrhoea may complicate surgery for proximal femoral fracture. We sought to determine whether a change in antibiotic policy in our unit influenced rates of infection with C. difficile following hip fracture surgery.

Methods: A 4 year case controlled study. A change in antibiotic prophylaxis was introduced during a 3 month period in 2005. Infection rates with C. difficile were compared for 2 years either side of this period. The initial regimen was one of three doses of cefuroxime (1.5 g). The new regimen is a single dose of cefuroxime (1.5 g) with gentamicin (240 mg) at induction. Infection was defined as diarrhoea with a positive isolate within 30 days of surgery.

Results: Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture. Following the change, 899 patients underwent surgery over the period March 2005 to March 2007. 38 patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group following the change in prophylaxis (P=0.009). Patients with C difficile infection also had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality.

Discussion: The main challenges regarding antibiotic selection are failure of prophylaxis, often because of infection with MRSA, and C. difficile-associated diarrhoea as a consequence of antibiotic prophylaxis. Infection with C. difficile is reduced with the new regimen. We advocate the use of the new regimen as an effective alternative to multiple dose cephalosporins for the prevention of C. difficile infection in this group of high risk patients.

Introduction: Controversy continues over the value of routine ultrasound hip screening and the question of whether the outcome of hips with dysplasia detected by ultrasound can be improved with treatment. Graf describes a group of infants in whom ultrasound demonstrates a hip that is in joint and centred yet severely dysplastic. These are classified as Grade 2c and are important because, although they may be clinically stable on presentation, they are at risk of progressing to dislocation.

Method: Cases were identified in which failure to recognize and/or treat Grade 2c hips lead to subluxation or dislocation of the joint. They were collected from centres where neonates had ultrasound examination of the hip as part of a selected screening program.

Results: Eight cases from four UK centres, showing deterioration in untreated Grade 2c hips. All were identified on retrospective Graf grading. Five patients underwent open reduction.

Discussion: The Graf method of hip ultrasound examination has not been widely accepted in the UK. Some authors believe that stable dysplastic hips will correct with growth and that treatment confers no specific advantage. However, an advantage of Graf’s method is that it can detect the centred, frequently ‘stable’ hip that will deteriorate in time; the Grade 2c hip. These cases illustrate the importance of recognising and appropriately managing this group of patients who will account for a proportion of late presenting cases of DDH.